Surgical treatment of salivary malignant tumors

A Retrospective 8-Year Single Institutional Study in Germany Regarding Diagnosis, Treatment, and Outcome of Malignant Parotid Tumors

This study sought to comprehensively evaluate the diagnosis, therapeutic interventions, and outcomes of individuals afflicted with malignant parotid tumors at a tertiary care otolaryngology department in Heilbronn, Germany, spanning the years 2010-2018. The primary objective was to juxtapose this dataset with findings from analogous single and multicenter investigations. We conducted a meticulous analysis of electronic medical records pertaining to 45 patients subjected to primary parotid cancer treatment. The male-to-female ratio was 3:2, with an average age of 61 years. Predominant histological types included mucoepidermoid and squamous cell carcinomas, with ultrasound emerging as the predominant diagnostic modality (97.8% sensitivity). Intraoperative frozen sections exhibited a high level of sensitivity. Notably, lymph node metastasis was prevalent in T3 tumors, frequently located intraparotid and at Neck level II. Solely one patient exhibited distant metastases (pulmonary). All patients underwent parotidectomy, and 29% necessitated a secondary procedure due to positive resection margins. Postoperative complications encompassed facial nerve palsy, seromas, and salivary fistulas. Adjuvant radiotherapy (38%) was recommended for high-grade tumors, T3/T4 stage, N+, perineural invasion (PNI), and positive or uncertain surgical margins. Neck dissection was executed in 67% of instances, with 20% revealing occult lymph node metastases. Recurrence manifested in 22% of patients, primarily as locoregional recurrence (80%) and distant metastases (20%). The 3-year recurrence-free survival (RFS), cancer-specific survival (CSS), and overall survival (OS) rates stood at 72.1%, 91.9%, and 87.5%, respectively. Noteworthy factors influencing RFS included preoperative facial palsy, T stage, resection margins, and PNI. In summary, the management of parotid cancer involving surgical interventions, neck dissection, and radiotherapy in high-risk patients yielded commendable outcomes with minimal complications, showcasing survival rates exceeding 70%. Timely diagnosis at an early stage is imperative for achieving tumor-free margins and enhancing survival rates. More assertive therapeutic strategies are advocated for cases presenting with preoperative facial nerve palsy and PNI.

The Number of Positive Lymph Nodes Instead of Extranodal Extension and Nodal Diameter is an Independent Predictor of Survival and Treatment Outcome of High-Grade Parotid Gland Carcinoma

BACKGROUND

There is emerging evidence that current 8th edition of the American Joint Committee staging system is not sensitive enough to predict parotid gland carcinoma (PGC) survival outcomes.

PURPOSE

The present study aimed to analyze pathological nodal factors related to survival and treatment outcomes in a cohort of patients surgically treated with PGC.

STUDY DESIGN, SETTING, SAMPLE

We performed a retrospective cohort study of consecutive patients surgically treated with PGC at the authors' institution from January 1993 to December 2018. The inclusion criteria were as follows: confirmed high-grade parotid gland malignancy on histopathology first surgical treatment of the parotid cancer with neck dissection with curative intent at the study clinic; and sufficient data for review. The exclusion criteria were previous treatment in another institution, low-grade carcinomas, cases where neck dissection was not performed, incurable local disease and distant metastases at the time of first diagnosis, and patients lost to follow-up.

PREDICTOR VARIABLE

Predictor variable comprised pathological nodal factors grouped as the number of cervical node metastases, extranodal extension (ENE), largest diameter of nodal metastasis, and involvement of parotid lymph nodes.

MAIN OUTCOME VARIABLES

Outcomes evaluated were overall survival (OS), disease-specific survival (DSS), recurrence-free survival (RFS), locoregional recurrence-free survival, and distant metastasis-free survival (DMFS). OS was calculated from the day of biopsy or definitive surgery to the last known hospital follow-up date or the date of death found in the hospital records or social security data. DSS was calculated from the day of biopsy or definitive surgery until the last known follow-up or death from PGC reported in the patient record. Patients who died from causes other than the disease being studied are not counted in this measurement. Treatment outcome was evaluated through the occurrence of locoregional relapse of the disease or development of distant metastases. RFS was defined as the time from the date of biopsy or definitive surgery to the date of locoregional recurrence free survivalor DMFS reported in the patient record.

COVARIATES

Covariates were composed of a set of heterogeneous variables grouped into the following categories: demographic, pathologic, and clinical.

ANALYSES

Unadjusted and adjusted hazard ratios for each variable were calculated with univariate and multivariable Cox regression. The tatistical significance was defined at a P value of < .05.

RESULTS

The cohort of 112 patients included 62 males (55%) and 50 (45%) females. The mean age of the patients was 60.52 ± 15.22 years. The median follow-up time was 59 months (3-221 months). Adenoid cystic carcinoma was the most common tumor type with the incidence of 45%. Cumulative OS for the 5-and 10-year follow-up period was 75 and 61%, respectively. Locoregional recurrences occurred with 27 patients (24%), distant metastases occurred with 25 patients (22%), and both were diagnosed with 5 patients (6%). The number of metastatic nodes was the most important nodal prognostic factor related to OS (P = .02; HR = 2.67; CI = 0.03-6.35), DSS (P = .011; HR = 2.55; CI = .61-6.83), and DMFS (P = .005; HR = 2.85; CI = 0.12-4.76). The presence of pathological parotid nodes was associated with poorer RFS (P = .015; HR = 3.45; CI = 0.25-6.02).

CONCLUSION AND RELEVANCE

The number of metastatic lymph nodes, instead of ENE and largest nodal diameter, was the contributing factor associated with survival and treatment outcomes of surgically treated patients with high-grade PGC. Since the main function of staging system is to predict outcomes, the significance of ENE and nodal dimension in salivary gland cancer staging system requires further clarification. An important finding in the present study was that the presence of positive parotid lymph nodes was associated to locoregional treatment failure.

Impact of facial nerve resection in parotid cancer abutting the facial nerve without preoperative paralysis: A multicentric propensity score-based analysis

OBJECTIVES

The management of the facial nerve (FN) is a major issue in parotid cancer, especially when there is no preoperative facial palsy and FN invasion is discovered intraoperatively. The aim of this study was to assess the impact of FN resection in patients with parotid cancer abutting the FN, without pretreatment facial palsy, using a propensity score matching.

MATERIALS AND METHODS

Data from all patients treated between 2009 and 2020 for a primary parotid cancer abutting or invading the FN but without pretreatment facial palsy were extracted from the national multicentric REFCOR database. Three different definitions of tumors abutting the FN were used for sensitivity analyses, in a retrospective setting. Propensity score matching was used to assess the impact of FN resection on disease-free survival (DFS), overall survival (OS) and locoregional recurrence-free survival (LRRFS).

RESULTS

A total of 163 patients with parotid cancer abutting or invading the FN without pretreatment facial palsy were included. Among them, 99 patients (61 %) underwent FN resection. After overlap weighting and multiple imputation, no benefit of FN resection over preservation was found in terms of OS (HR = 1.21, p = 0.6), DFS (HR = 0.88, p = 0.5) and LRRFS (HR = 0.99, p = 1). Sensitivity analyses revealed similar results, and no significant efficacy was found in the subgroup analyses.

CONCLUSION

In this retrospective study with propensity score analysis, FN resection did not improve survival outcomes in patients without preoperative facial palsy treated surgically for a primary parotid cancer abutting the FN. In line with recent guidelines, the results of this study suggest that FN preservation should be considered whenever possible in this specific group of patients.

Comparison of Peptidomes Extracted from Healthy Tissue and Tumor Tissue of the Parotid Glands and Saliva Samples

Salivary gland tumors are highly variable in clinical presentation and histology. The World Health Organization (WHO) classifies 22 types of malignant and 11 types of benign tumors of the salivary glands. Diagnosis of salivary gland tumors is based on imaging (ultrasound, magnetic resonance imaging) and fine-needle aspiration biopsy, but the final diagnosis is based on histopathological examination of the removed tumor tissue. In this pilot study, we are testing a new approach to identifying peptide biomarkers in saliva that can be used to diagnose salivary gland tumors. The research material for the peptidomic studies was extracts from washings of neoplastic tissues and healthy tissues (control samples). At the same time, saliva samples from patients and healthy individuals were analyzed. The comparison of the peptidome composition of tissue extracts and saliva samples may allow the identification of potential peptide markers of salivary gland tumors in patients' saliva. The peptidome compositions extracted from 18 tumor and 18 healthy tissue samples, patients' saliva samples (11 samples), and healthy saliva samples (8 samples) were analyzed by LC-MS tandem mass spectrometry. A group of 109 peptides was identified that were present only in the tumor tissue extracts and in the patients' saliva samples. Some of the identified peptides were derived from proteins previously suggested as potential biomarkers of salivary gland tumors (ANXA1, BPIFA2, FGB, GAPDH, HSPB1, IGHG1, VIM) or tumors of other tissues or organs (SERPINA1, APOA2, CSTB, GSTP1, S100A8, S100A9, TPI1). Unfortunately, none of the identified peptides were present in all samples analyzed. This may be due to the high heterogeneity of this type of cancer. The surprising result was that extracts from tumor tissue did not contain peptides derived from salivary gland-specific proteins (STATH, SMR3B, HTN1, HTN3). These results could suggest that the developing tumor suppresses the production of proteins that are essential components of saliva.

Lymph node surgery for salivary gland cancer: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the indications for neck dissection in the management of parotid, submandibular or minor salivary gland cancers depending on the clinical situation: i.e., clinical lymph node involvement (cN+) or not (cN0); low or high risk of occult nodal metastasis; diagnosis of malignancy before, during or after surgery.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group which drafted a narrative review of the literature published on Medline and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group according to the formal consensus method.

RESULTS

In cN+ salivary gland cancer, ipsilateral neck dissection is recommended. In cN0 salivary gland cancer, ipsilateral neck dissection is recommended, except for tumors at low risk of occult nodal metastasis. If definitive pathology reveals a high risk of occult nodal involvement, additional neck treatment is recommended: ipsilateral neck dissection or elective nodal irradiation.

CONCLUSION

The rate of occult lymph node involvement, and therefore the indication for elective neck dissection, depends primarily on the pathologic grade of the salivary gland cancer.

Surgery of major salivary gland cancers: REFCOR recommendations by the formal consensus method

OBJECTIVE

To determine the role of surgery of the primary tumor site in the management of primary major salivary gland cancer.

MATERIAL AND METHODS

The French Network of Rare Head and Neck Tumors (REFCOR) formed a steering group, which drafted a non-systematic narrative review of the literature published on Medline, and proposed recommendations. The level of adherence to the recommendations was then assessed by a rating group, according to the formal consensus method.

RESULTS

Treatment of salivary gland tumor is mainly surgical. The gold standard for parotid cancer is a total parotidectomy, to obtain clear margins and remove all intraparotid lymph nodes. For low-grade tumors, partial parotidectomy with wide excision of the tumor is acceptable in the case of postoperative diagnosis on definitive histology. In the event of positive margins on definitive analysis, revision surgery should be assessed for feasibility, and performed if possible.

CONCLUSION

Treatment of primary major salivary gland cancer is based on surgery with clear resection margins, as far away as possible from the tumor. The type of surgery depends on tumor location, pathologic type and extension.

Occult Nodal Metastases in Individuals with Clinically Node-Negative Salivary Gland Malignancies

OBJECTIVES

Salivary gland malignancies comprise a heterogeneous group of pathologies, for which treatment of the clinically negative neck may vary depending on numerous factors. Herein we present data on occult nodal metastases (ONM) as well as survival and recurrence from a large series of cN0 salivary gland malignancies.

METHODS

Retrospective chart review was conducted on 532 patients, with 389 patients with major salivary gland cancers and 143 patients with minor salivary gland cancers. Demographic and treatment data were included and rates of ONM, overall survival, local recurrence, regional recurrence, and distant recurrence were analyzed.

RESULTS

We found that the overall rate of ONM for parotid was 27% (63/235), for submandibular/sublingual was 35% (18/52), and for minor was 15% (4/26). Analysis of ONM rate at each nodal level was also performed, finding higher rates of level IV and V ONM than prior studies. Submandibular/sublingual and minor salivary gland malignancies showed a predominance of ONMs at levels I-III. Our survival and recurrence rates were similar to those found in previous studies.

CONCLUSION

Our data also demonstrate a predominance of ONM in levels I-III for submandibular/sublingual and minor salivary gland cancers, suggesting elective dissection in these levels.

LEVEL OF EVIDENCE

4 Laryngoscope, 134:1705-1715, 2024.

Malignant sublingual gland tumors: A single-center retrospective analysis of 79 patients

OBJECTIVES

To analyze and summarize the clinicopathological features, risk factors for cervical nodal metastasis, and prognostic factors of malignant sublingual gland tumors (MSLGT).

METHODS

Patients diagnosed with MSLGT were retrospectively reviewed from January 2005 to December 2017 at Shanghai Ninth Hospital. The clinicopathological features were summarized, and the correlations between clinicopathological parameters, cervical nodal metastasis, and local-regional recurrence were evaluated using the Chi-square test. Kaplan-Meier method and Cox regression analysis were performed to assess the survival and independent prognostic factors.

RESULTS

Seventy-nine patients were included, and the 5-year overall survival and disease-free survival rates was 85.7% and 71.7%, respectively. Gender and clinical tumor stage were risk factors for cervical nodal metastasis. Tumor size and pathological lymph node (LN) stage were independent prognostic factors for adenoid cystic carcinoma (ACC) of the sublingual gland; while age, pathological LN stage, and distant metastasis were prognostic factors for patients with non-ACC of the sublingual gland. Patients with higher clinical stage were more likely to undergo tumor recurrence.

CONCLUSIONS

Malignant sublingual gland tumors are rare, and neck dissection should be performed in male MSLGT patients with higher clinical stage. Among patients with both ACC and non-ACC MSLGT patients, pN+ indicate a poor prognosis.

Comparison of Partial Versus Superficial or Total Parotidectomy for Superficial T1-2 Primary Parotid Cancers

OBJECTIVES

This study aimed to compare the oncological outcomes of partial versus superficial or total parotidectomy for superficial T1 or T2 primary parotid cancers and investigate their prognostic factors and recurrence patterns.

METHODS

The medical records of 77 patients with T1-2 primary parotid malignancies between May 2003 and March 2022 were retrospectively reviewed. Univariate and multivariate analyses were performed to evaluate the prognostic factors associated with overall survival, disease-free survival, and local and distant recurrence.

RESULTS

The average follow-up duration was 70.2 months (range, 12-202 months). The 5-year overall and disease-free survival rates were 88.7% and 77.1%, respectively. Twenty-two patients underwent partial parotidectomy, and 55 underwent superficial or total parotidectomy. There were no significant differences in the disease recurrence (P=0.320) and mortality rates (P=0.884) of the partial and superficial or total parotidectomy groups. The mean duration of surgery was shorter and the overall complication rates were significantly lower in the partial group than in the superficial or total parotidectomy group (P=0.049). Sixteen cases of recurrence occurred during the study period (20.8%). Univariate analyses showed that high-grade tumors (P=0.006), lymphovascular invasion (P=0.046), and regional lymph node metastasis (P=0.010) were significant risk factors for disease recurrence. Multivariate analysis identified regional lymph node metastasis as an independent prognostic factor for disease recurrence (P=0.027), and lymphovascular invasion as an independent prognostic factor for overall survival (P=0.033).

CONCLUSION

The conservative surgical approach of partial parotidectomy can yield oncological outcomes comparable to those of superficial or total parotidectomy with careful patient selection in T1-2 parotid cancers.

Research trends and perspectives on immediate facial reanimation in radical parotidectomy (Review)

For patients diagnosed with advanced malignant parotid tumour, radical parotidectomy with facial nerve sacrifice is part of the treatment. Multiple surgical techniques have been developed to cure facial paralysis in order to restore the function and aesthetics of the face. Despite the large number of publications over time on facial nerve reanimation, a consensus on the timing of the procedure or the donor graft selection has remained to be established. Therefore, the aim of the present study was to conduct a bibliometric analysis to identify and analyse scientific publications on the reconstruction of the facial nerve of patients who underwent radical parotidectomy with facial nerve sacrifice. The analysis on the topic was conducted using the built-in tool of the Scopus database and VOSviewer software. The first 100 most cited articles were separately reviewed to address the aim of the study. No consensus was found regarding the recommended surgical techniques for facial nerve reanimation. The most used donor cranial nerves for transfer included the following: Masseteric branch of the V nerve, contralateral VII nerve with cross-face graft, the XI nerve and the XII nerve. The best timing of surgery is also controversial depending on pre-exiting pathology and degree of nerve degeneration. However, most of the clinical experience suggests facial nerve restoration immediately after the ablative procedure to reduce complications and improve patients' quality of life.

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.

Surgical Treatment of Carcinomas of the Oral Minor Salivary Glands-Oncological Outcome in Dependence of Tumor Entity and Therapeutic Strategies

The aim of this study was to analyze the clinical outcomes of three types of minor salivary gland carcinomas (adenoid-cystic carcinomas (ACC), adeno carcinomas not otherwise specified (AC-NOS), and mucoepidermoid carcinomas (MEC)) after primary surgical therapy. A retrospective cohort study was designed and patients with cancer of the minor oral salivary glands treated in our department in the years 2011 to 2022 were included. Clinicopathological data were evaluated to compare overall survival and progression-free survival between the entities. Eighty-one patients were included. The rates of cervical metastases were 38.9% for ACC, 25% for MEC, and 9.1% for AC-NOS. ACC exhibited significantly higher rates of local and systemic disease recurrence (p = 0.02), and the presence of neck node metastases was confirmed as an independent prognostic factor for progression-free survival (p = 0.014). Treatment success in terms of oncological outcome varied significantly between the different entities and implies different treatment regimens for each tumor entity.

Diagnosis and Management of Parotid Gland Cancer with Focus on the Role of Preoperative Fine-Needle Aspiration Cytology: A 10-Year-Long Retrospective Study with 5-Year Follow-Up

Introduction

Salivary gland cancers represent a rare heterogeneous group of neoplasms with complex clinicopathological characteristics and distinct biological behaviour. The appropriate diagnosis and management of parotid gland cancer are challenging and should be based on the clinical, imaging, cytological, and histological features. The present study analysed the use of preoperative fine-needle aspiration cytology (FNAC) and intraoperative frozen section (FS) to guide the appropriate surgical and postoperative treatment of parotid gland cancers.

Materials and Methods

We selected 48 patients with primary malignancy of the parotid gland surgically treated between 1 January 2008 and 30 June 2017 at the Maxillo-Facial Surgery Division, University Hospital of Parma, Italy. The patients had postoperative histological diagnosis of malignant parotid cancer and were followed up for longer than 5 years.

Results

The 48 patients included in this study had a mean age of 56.7 years. The most frequent type of parotid gland cancer was carcinoma ex pleomorphic adenoma (22.9%), followed by mucoepidermoid carcinoma (16.7%) and acinic cell carcinoma (14.6%). All 48 patients underwent preoperative FNAC: 29 (60.4%) and 19 (39.6%) were suggestive of malignant and benign lesions, respectively. In 31 patients, intraoperative FS was performed.

Discussion

Compared to previous studies, the present study showed significantly lower diagnostic sensitivity of FNAC for parotid gland cancers. The preoperative diagnostic accuracy for suspected malignant cases may be improved by repeat analysis of the cytological specimen by experts, preoperative core needle biopsy, and/or intraoperative FS analysis of the suspected mass.

Histogram analysis of ultrasonographic images in the differentiation of benign and malignant parotid gland tumors

OBJECTIVE

We evaluated the diagnostic value of histogram analysis (HA) using ultrasonographic (US) images for differentiation among pleomorphic adenoma (PA), adenolymphoma (AL), and malignant tumors (MT) of the parotid gland.

STUDY DESIGN

Preoperative US images of 48 patients with PA, 39 patients with AL, and 17 patients with MT were retrospectively analyzed for gray-scale histograms. Nine first-order texture features derived from histograms of the tumors were compared. Area under the receiver operating characteristic curve (AUC) was used to evaluate the diagnostic performance of texture features. The Youden index maximum exponent was used to calculate sensitivity and specificity.

RESULTS

Statistically significant differences were discovered in Mean and Skewness HA values between PA and AL (P<0.001), and in Mean values between AL and MT (P<0.001). However, comparison of PA and MT showed no statistically significant differences (P>0.01). Excellent discrimination was detected between PA and AL (AUC=0.802), and between AL and MT (AUC=0.822). The combination of Mean plus Skewness improved discrimination between PA and AL (AUC=0.823) with sensitivity values reaching 1.00. However, Mean plus Skewness applied to differentiate PA from AL and Mean values applied to distinguish AL and MT resulted in low specificity, indicating many false positive interpretations.

CONCLUSIONS

Histogram analysis is useful for differentiating PA from AL and AL from MT but not PA from MT.

Major and minor salivary gland cancers: A multicenter retrospective study

BACKGROUND

Most of the studies on salivary gland cancers are limited for various reasons such as being single-center, small number of patients, including only major or minor SGCs, or only including epidemiological data.

METHODS

A total of 37 medical oncology clinics from different regions of Turkey participated in this retrospective-multicenter study. The analyzed data included clinical and demographical features, primary treatment, metastasis localizations, and treatments and includes certain pathologic features.

RESULTS

The study included data from a total of 443 SGCs. 56.7% was in major salivary glands and 43.3% was in minor salivary glands. Distant metastasis in the major SGCs was statistically significantly more common than in the minor SGCs, locoregional recurrence was statistically significantly more common in the minor SGCs than in the major SGCs (p = 0.003).

CONCLUSIONS

Epidemiological information, metastasis and recurrence patterns, treatment modalities, and survival analysis of the patients over 20 years of follow-up are presented.

Comparative analysis of benign and malignant parotid gland tumors: A retrospective study of 992 patients

OBJECTIVE

We analyzed and compared the clinical characteristics of benign and malignant parotid gland tumors.

PATIENTS AND METHODS

A total of 992 patients who underwent surgical treatment for parotid gland tumors from January 2010 to December 2020 were included in this study. This study population was subdivided into benign (n = 812, 81.9 %) and malignant parotid gland tumors (n = 180, 18.1 %).

RESULTS

Pleomorphic adenoma is the most common benign tumor and mucoepidermoid carcinoma is the most common malignant tumor. The patients with malignant parotid gland tumors were older than the patients with benign lesions. The duration of symptoms was longer in patients with benign parotid gland tumors compared to those with malignant lesions. The size of the malignant tumors was larger than that of the benign lesions. Preoperative fine-needle aspiration cytology had a diagnostic sensitivity of 50.3 %, diagnostic specificity of 98.7 %, a positive predictive value of 89.5 %, a negative predictive value of 89.9 %, and accuracy of 89.9 % for diagnosing malignant parotid gland tumors. For benign parotid gland tumors, superficial parotidectomy was most frequently performed, and for malignant parotid gland tumors, total parotidectomy was most frequently performed. Facial palsy was observed in 19.4 % of the patients with malignant parotid gland tumors compared to 5.4 % of those with benign tumors.

CONCLUSION

The clinical features of benign and malignant parotid gland tumors showed differences in age, symptoms, duration of symptoms, size and site of the parotid tumors, surgical procedures, and postoperative facial nerve palsy.

Survival in Patients with Primary Parotid Gland Carcinoma after Surgery—Results of a Single-Centre Study

This study aims to analyse a single-centre cohort series of patients who underwent parotidectomy for primary malignant parotid tumours. A retrospective chart review of 64 consecutive patients treated from November 2010 to March 2022 was performed. Outcomes were analysed by Kaplan-Meier curves. Sixty-four patients with a primary parotid malignancy were included in the study, with one bilateral case in this cohort. Patients were classified as stage I–II in 39 cases and stage III–IV in 26 cases. The five-year overall survival (OS), disease-specific survival (DSS), local relapse-free survival (LRFS), and distant metastasis-free survival (DMFS) rates were 78.4%, 89%, 92.5%, and 87.1%, respectively. Univariate analysis showed that high-risk histology, stage IV disease, lymphovascular invasion, perineural invasion, node metastasis, skin involvement, facial nerve involvement, and positive or close margins were risk factors associated with poorer outcomes. At present, the best evidence suggests that radical surgery should be the standard approach, and adjuvant therapy, in terms of radiotherapy/chemoradiotherapy, is recommended in patients with risk factors.

Primary and Secondary Tumors of the Parotid Gland: Clinical Features and Prognosis

Primary and secondary malignant tumors can affect the parotid gland. The aim of this retrospective study was to evaluate the clinical features and prognosis of malignant epithelial tumors of the parotid gland. In particular, a comparison between primary and secondary cancer and survival analyses were performed. Eighteen patients with primary cancer and fifteen with intraparotid metastasis from cutaneous squamous cell carcinoma were included. A chart review was performed to collect clinical data (age, sex, smoking, alcohol consumption, tumor stage, type of surgical procedure, complications, recurrence and death). The majority of primary tumors were early (T1-2 N0, 83%) with mucoepidermoid carcinoma being the most common (33%). Secondary tumors were mostly staged P2 (53%) and N0 (67%). Subjects with secondary tumors were older than those with primary cancer. Post-operative permanent facial palsy was observed in 5 patients (17%) with primary cancer and 9 (60%) with secondary tumors (p = 0.010). Two-year overall survival for primary and secondary parotid cancer was 76.58% and 43.51%, respectively (p = 0.048), while 2-year disease-free survival was 76.05% and 38.50%, respectively (p = 0.152). In conclusion, secondary cancer of the parotid gland has worse survival than primary tumors. In the future, the implementation of multimodality treatment of intraparotid metastases is necessary to improve oncologic outcomes.

Salivary gland cancer: ESMO-European Reference Network on Rare Adult Solid Cancers (EURACAN) Clinical Practice Guideline for diagnosis, treatment and follow-up

•This ESMO–EURACAN Clinical Practice Guideline provides key recommendations for managing salivary gland cancer. •The guideline covers clinical and pathological diagnosis, staging and risk assessment, treatment and follow-up. •Treatment algorithms for parotid, submandibular, sublingual and minor salivary gland cancer are provided. •The author group encompasses a multidisciplinary group of experts from different institutions and countries in Europe. •Recommendations are based on available scientific data and the authors’ collective expert opinion.

The Therapeutic Landscape of Salivary Gland Malignancies-Where Are We Now?

Salivary gland malignancies (SGMs) account for less than 5% of new diagnoses in head and neck tumors. If feasible, surgery is the preferred treatment modality. Nevertheless, some malignancies have a tendency of recurrence, with possible distant metastasis. Alternative treatment strategies, such as primary radiation or chemotherapeutics, often present low response rates. As a result, there is an unmet need for novel therapeutic approaches. Nowadays, target-based therapies (e.g., small inhibitors and immunotherapy) are used by the medical oncologist for possible treatment of advanced SGMs. Based on recent published trials, some novel treatments may provide additional disease control for some patients. However, sample sizes are small, the general findings are unsatisfactory, and a lot of uncertainties remain to be elucidated. Nevertheless, research shows that patients do not benefit from blind administration of systemic treatments and therefore a more personalized approach is highly needed. The aim of this review paper is to summarize the most recent advances in the biological understanding and molecular pathways of salivary gland cancers, the association of these pathways with the current treatments used and their implications for more personalized targeted-based therapies.

Salivary gland cancers in elderly patients: challenges and therapeutic strategies

Salivary gland carcinomas (SGCs) are the most heterogeneous subgroup of head and neck malignant tumors, accounting for more than 20 subtypes. The median age of SGC diagnosis is expected to rise in the following decades, leading to crucial clinical challenges in geriatric oncology. Elderly patients, in comparison with patients aged below 65 years, are generally considered less amenable to receiving state-of-the-art curative treatments for localized disease, such as surgery and radiation/particle therapy. In the advanced setting, chemotherapy regimens are often dampened by the consideration of cardiovascular and renal comorbidities. Nevertheless, the elderly population encompasses a broad spectrum of functionalities. In the last decades, some screening tools (e.g. the G8 questionnaire) have been developed to identify those subjects who should receive a multidimensional geriatric assessment, to answer the question about the feasibility of complex treatments. In the present article, we discuss the most frequent SGC histologies diagnosed in the elderly population and the relative 5-years survival outcomes based on the most recent data from the Surveillance, Epidemiology, and End Results (SEER) Program. Moreover, we review the therapeutic strategies currently available for locoregionally advanced and metastatic disease, taking into account the recent advances in precision oncology. The synergy between the Multidisciplinary Tumor Board and the Geriatrician aims to shape the most appropriate treatment pathway for each elderly patient, focusing on global functionality instead of the sole chronological age.

A Rare Case of Primary Squamous Cell Carcinoma of the Submandibular Salivary Gland: Brief Overview of Diagnostic Ambiguity and Treatment Challenges

Primary squamous cell carcinoma of the submandibular salivary gland is a rarity with obscure etiology and atypical presentation. The features include a progressively enlarging swelling in the lateral neck just below the mandible, which is rarely tender. Surgery is the mainstay of the treatment, and the role of adjuvant therapies is not defined. Precise diagnosis demands a step-by-step systematic approach to exclude the presence of any index tumor. A 65-year-old countryside male presented to our institute with a complaint of submandibular swelling of the right side. After the exclusion of the primary, he was treated surgically with safe margins, ipsilateral comprehensive neck dissection, and adjuvant therapy. One month post-chemoradiotherapy, the patient developed a second primary in the contralateral submandibular region with lung metastasis and succumbed to death due to malignant cachexia. The stage of the disease at presentation, bone and skin involvement, lymphovascular invasion, poorer differentiation, and distant metastasis are associated with dismal outcomes. An early diagnosis and comprehensive surgical management with adjuvant chemoradiotherapy must be accomplished.

Management of malignant submandibular gland tumors: A 30-year experience from a single center

OBJECTIVE

Owing to histologic heterogeneity, biological behavior, and rarity, recommendations for the treatment of malignant submandibular gland tumors (MSGT) are inconsistent. The aim of this study was to present a single-center experience in the treatment of MSGT with an emphasis on surgical treatment, including indication on elective neck dissection (END).

STUDY DESIGN

Twenty-four MSGT were primary surgically treated (gland excision with neck dissection). Their records were retrospectively collected and analyzed.

RESULTS

The most frequent histology was adenoid cystic carcinoma (41.6%), followed by mucoepidermoid carcinoma (25%) and carcinoma ex pleomorphic adenoma (16.7%). There were 18 elective and 6 therapeutic neck dissections. Histopathologic examination confirmed 29% (7/24) of positive neck dissection specimens. The Kaplan-Meier analysis presented rates of disease-specific survival, disease-free survival, and overall survival (OS) of 81%, 78%, and 52% at 5 years, respectively. Patients undergoing postoperative radiotherapy had significantly higher OS rates compared with patients treated with surgery alone (P = .0209).

CONCLUSION

Results of this study suggest that END has questionable benefit in early stage MSGT. Elective selective neck dissection levels I-III is recommended in high-grade and advanced stage MSGT without evidence of multilevel lymphadenopathy.

A nomogram based on clinical information, conventional ultrasound and radiomics improves prediction of malignant parotid gland lesions

Although conventional ultrasound (CUS) allows for clear detection of parotid gland lesions (PGLs), it fails to accurately provide benign-malignant differentiation due to overlapping morphological features. Radiomics is capable of processing large-quantity volume of data hidden in CUS image undiscovered by naked eyes. The aim was to explore the potential of CUS-based radiomics score (Rad-score) in distinguishing benign (BPGLs) and malignant PGLs (MPGLs). A consecutive of 281 PGLs (197 in training set and 84 in test set) with definite pathological confirmation was retrospectively enrolled. 1465 radiomics features were extracted from CUS images and Rad-score was constructed by using Least Absolute Shrinkage and Selection Operator (LASSO) algorithm. Different nomogram models, including clinic-radiomics (Clin + Rad-score), CUS-clinic (CUS + Clin) and combined CUS-clinic-radiomics (CUS + Clin + Rad-score), were built using logistic regression. The diagnostic performance of different models were calculated and compared by area under receiver operating curve (AUC) and corresponding sensitivity and specificity. Finally, 26 radiomics features were independent signatures for predicting MPGLs, with MPGLs having higher Rad-scores in both cohorts (both P < 0.05). In the test population, CUS + Clin + Rad-score obtained an excellent diagnostic result, with significantly higher AUC value (AUC = 0.91) when compared to that of CUS + Clin (AUC = 0.84) and Clin + Rad-score (AUC = 0.74), respectively (both P < 0.05). In addition, the sensitivity of this combined model was higher than that of single Rad-score model (100.00% vs. 71.43%, P = 0.031) without compromising the specificity value (82.86% vs. 88.57%, P = 0.334). The calibration curve and decision curve analysis also indicated the clinical effectiveness of the proposed combined nomogram. The combined CUS-clinic-radiomics model may help improve the discrimination of BPGLs from MPGLs.

Diagnosis and management of malignant sublingual gland tumors: a narrative review

OBJECTIVE

In this article we review the literature on the malignant sublingual gland tumors from a surgical perspective.

BACKGROUND

Sublingual gland tumors occur with a very low incidence and most are malignant tumors. The extent of treatment, clinical outcomes and prognosis of malignant sublingual gland tumors have not been well defined, due to the rarity of this disease.

METHODS

A database search using Web of Science (https://webofknowledge.com/) and PubMed (https://pubmed.ncbi.nlm.nih.gov/) was conducted. The following keywords were used in the search: "sublingual gland tumor", AND "malignancy".

CONCLUSIONS

Although the sublingual glands are among the major salivary glands, they share common anatomical characteristics with minor salivary gland tumors. Therefore, the tumors from the sublingual gland may have different clinical behaviors from the other major salivary gland tumors. The sublingual glands are small without a true surrounding capsule of the glands; the extra-parenchymal extension is very common in sublingual gland tumors. Furthermore, the sublingual glands are located in close proximity to the lingual nerve, the submandibular gland-duct system and the mandible. Thus, the surgical approach to the malignant sublingual gland tumor should include the adequate management of neighboring structures. In addition, adjuvant radiation therapy provides a survival benefit for patients with malignant sublingual gland tumors, which have adverse features. This article summarizes the clinical characteristics and unique features of malignant sublingual gland tumors based on previous reports, and provides clinical information regarding the sublingual gland tumors to increase awareness of primary physicians as well as patients.

Prognostic indicators in clinically node-negative malignant primary salivary tumours of the parotid: A multicentre experience

OBJECTIVES

Nodal metastasis is an important prognosticator in primary parotid cancers. The management of the clinically node-negative neck is an area lacking consensus. This study investigates the occult nodal metastasis rate, and prognostic indicators in primary parotid cancers.

MATERIALS AND METHODS

We performed a multicentre retrospective case note review of patients diagnosed and treated surgically with curative intent between 1997 and 2020. Demographic, clinic-pathological and follow-up data was recorded.

RESULTS

After exclusions, 334 patients were included for analysis, with a median follow-up of 48 months. The overall rate of occult lymph node metastasis amongst patients undergoing elective neck dissection was 22.4%, with older age, high-grade and more advanced primary tumours being associated with higher rates. On multivariable analysis, age ≥ 60 years (HR = 2.69, p = 0.004), high-grade tumours (HR = 2.70, p = 0.005) and advanced primary tumours (pT3-4, HR = 2.06, p = 0.038) were associated with worse overall survival. Occult nodal metastasis on final pathology was associated with a close-to-significant reduction in regional recurrence free survival (HR = 3.18, p = 0.076).

CONCLUSION

This large series confirms the significant occult lymph node metastasis rate in primary parotid cancer, and demonstrates the importance of primary histology, tumour grade and stage in predicting survival outcome. This data supports the use of elective neck dissection in patients with high-risk tumours.

Characterization of tumor-associated MUC1 and its glycans expressed in mucoepidermoid carcinoma

Mucoepidermoid carcinoma (MEC) is one of the most frequently misdiagnosed tumors. Glycans are modulated by malignant transformation. Mucin 1 (MUC1) is a mucin whose expression is upregulated in various tumors, including MEC, and it has previously been investigated as a diagnostic and prognostic tumor marker. The present study aimed to reveal the differences in the mucin glycans between MEC and normal salivary glands (NSGs) to discover novel diagnostic markers. Soluble fractions of salivary gland homogenate prepared from three MEC salivary glands and 7 NSGs were evaluated. Mucins in MEC and NSGs were separated using supported molecular matrix electrophoresis, and stained with Alcian blue and monoclonal antibodies. The glycans of the separated mucins were analyzed by mass spectrometry. MUC1 was found in MEC but not in NSGs, and almost all glycans of MUC1 in MEC were sialylated, whereas the glycans of mucins in NSGs were less sialylated. The core 2 type glycans, (Hex)₂(HexNAc)₂(NeuAc)₁ and (Hex)₂(HexNAc)₂(NeuAc)₂, were found to be significantly abundant glycans of MUC1 in MEC. MEC markedly produced MUC1 modified with sialylated core 2 glycans. These data were obtained from the soluble fractions of salivary gland homogenates. These findings provide a basis for the utilization of MUC1 as a serum diagnostic marker for the preoperative diagnosis of MEC.

[Surgical Management of Salivary Gland Carcinoma]

Salivary gland carcinomas are very threatening diseases. The patient's survival depends to a large extent on planning and performing the resection. This article provides assistance with the most important surgical decisions. Using illustrative examples and practical tips the article shows how oncological salivary gland surgery can be successful.

Surgical treatment of the neck in patients with salivary gland carcinoma

BACKGROUND

Elective neck dissection (END) in patients with salivary gland carcinoma is controversial and there are no universally accepted guidelines.

METHODS

Patients were identified from the Danish Head and Neck Cancer Group. Between 2006 and 2015, 259 patients with primary salivary gland carcinoma were treated with END. Variables potentially associated with regional metastases were analyzed using logistic regression. Neck recurrence-free survival was calculated using the Kaplan-Meier method.

RESULTS

Occult metastases were found in 36 of the patients treated with END (14%) and were particularly frequent among patients with T3/T4 tumors and high-grade histology tumors. In multivariate analyses, high-grade histology and vascular invasion were associated with occult metastases.

CONCLUSION

We recommend END of levels II and III for patients with high-grade or unknown histological grade tumors, and for T3/T4 tumors. Levels I, II, and III should be included in END in patients with submandibular, sublingual, or minor salivary gland carcinomas.

Analysis of local invasion and regional spread in malignant sublingual gland tumour: Implications for surgical planning

Malignant tumours arising from the sublingual glands are very rare, and the extent and frequency of local invasion or regional spread in malignant sublingual gland tumour (MSLT) has not been fully studied due to the disease rarity. To provide comprehensive features of local and regional spread of MSLT, we reviewed 20 surgical cases for detailed pathological analyses among 26 cases diagnosed as having primary MSLT. Adenoid cystic carcinoma (ACC) was the most common pathological subtype, followed by mucoepidermoid carcinoma. Disease-free and overall survivals at 5 years were 76.1 % and 77.7 %, respectively. High-grade malignant tumours and grade 2-3 ACC accounted for 41.7 % and 85.7 %. Clinical and pathological extraparenchymal extensions were found in 34.6 % and 80.0 %, respectively. Tumour invasion to the lingual nerve and submandibular gland/ductal system were also detected in 40.0 % and 28.6 %. The incidences of lingual nerve invasion in ACC and ACC ≥4 cm were 30.8 % and 42.9 %. Regional nodal involvement occurred in seven of 26 cases, and all metastatic lymph nodes were found in neck levels Ib and IIa. In summary, a significant portion of MSLT cases consisted of high-grade tumours and grade 2-3 ACC; therefore local invasion into adjacent structures should be cautiously evaluated in cases of MSLT.

Can the height of the parotid tumor be a predictor of malignancy?

Background

Accurate diagnosis of malignancy in the parotid gland before surgery is often challenging. Various clues should be used to increase the index of suspicion for malignancy. We hypothesized that malignant lesions of the parotid gland are located at the superior part of the gland compared to benign ones.

Methods

A total of 169 consecutive patients were included in this study whose medical records were retrospectively reviewed. Benign and malignant tumors were compared in size, height difference from five anatomical landmarks: hard palate, mastoid tip, earlobe, condylar head, and mandibular notch. The cutoff heights from significant landmarks (hard palate, condylar head) were estimated with ROC analysis and chi-square test.

Results

Twenty-nine patients (17.2%) were diagnosed with malignant and 140 patients (82.8%) as benign. The height differed significantly between benign and malignant tumors when the reference point was set for the hard palate (P=0.024) and the condylar head (P=0.049), with the cutoff height from reference points to be 22.5, 51.5 mm, respectively. Diagnostic values of parotid level difference presented higher sensitivity (75.9% for hard palate, 72.4% for condylar head vs. 47.8% for fine needle aspiration cytology) and lower false negative rate (24.1% for hard palate, 27.6% for condylar head vs. 52.2% for fine needle aspiration cytology) compared to fine needle aspiration cytology.

Conclusions

Malignant tumors of the parotid gland tend to locate at the superior part of the gland compared to benign tumors. Parotid tumors lying cephalad should raise an index of suspicion for malignancy. Height of the tumor in the parotid gland should be deliberately considered during the first encounter of the patient, which in turn could curate the next step in the diagnostic approach and treatment planning.

The impact of nodal status in major salivary gland carcinoma: A multicenter experience and proposal of a novel N-classification

OBJECTIVES

Despite differences in oncological behavior, the 8th edition of AJCC TNM staging currently proposes the same N-classification for major salivary glands (MSG) carcinoma and squamous cell carcinoma of the upper aerodigestive tract. The present study aims to investigate a more reliable definition of N-categories for MSG carcinoma.

MATERIALS AND METHODS

A retrospective multicenter study was performed, including 307 patients treated for primary MSG carcinoma from 1995 to 2019. Outcome measures included overall survival (OS), disease specific survival, and local, regional, and distant recurrence. Survival analysis was performed using log-rank test and Cox proportional-hazards model. Overall number (ON) and largest diameter (LD) of nodal metastases, including intra-parotid metastases, were considered to develop three novel proposals of N-classification; their performance were compared with the current TNM staging using Akaike information criterion (AIC), Bayesian information criterion (BIC), and Nagelkerke pseudo-R2.

RESULTS

Intra-parotid nodes, ON and LD of nodal metastases emerged as major prognosticators for OS, while extra-nodal extension did not impact on any survival. The current N-classification did not show a satisfactory OS stratification. Three novel N-classifications were developed according to number of metastatic nodes (0 vs 1-3 vs ≥ 4) and/or their maximum diameter (<20 mm vs ≥ 20 mm). They all showed better accuracy in OS stratification, and achieved better AIC, BIC and Nagelkerke pseudo-R2 indices when compared to current N-classification.

CONCLUSION

All the proposed N-classifications improved OS stratification and could help in defining a specific N-classification for MSG carcinoma. Their validation and assessment in an external cohort is needed.

Malignant tumours of the parotid gland: management of the neck (including the clinically negative neck) and a literature review

Major salivary gland malignancies are rare, constituting 1%-3% of head-neck tumours. The surgical management of the clinically negative neck (cN0) does not have a univocal consensus yet. We have carried out a retrospective study on 119 cases of malignant parotid tumours that were surgically treated between January 1999 and January 2014. Our aim was to analyse preoperative findings (cytotype, cTNM) and to correlate these with postoperative results (grading, histotype, occult neck metastasis) in patients with parotid tumours to obtain an appropriate indication for neck management. In cN0 patients with a T1, T2 low-grade cancer a wait-and-see approach is preferred. Instead, in cNO patients with high-grade or low-grade T3, T4 tumours an elective neck dissection (END) is always planned. Levels II, III and IV, at least, must be dissected. The decision to dissect level V or I depends on the location of the primary tumour. In the cN0 group 19 of 58 (32.7%) patients who underwent an END had occult metastases. In clinically positive neck (cN+) patients a Modified Radical Neck Dissection (MRND), at least, must be performed. The criteria to add adjuvant radiotherapy (PORT) include deep lobe parotid tumours, advanced lesions (T3-T4), microscopic (R2) or macroscopic (R1) residual disease after surgery, high grade tumours, perineural diffusion, lymph node metastasis, capsular rupture, and local recurrence after previous surgery. Kaplan-Meier analyses have shown a reduction in the overall survival (OS) from 100% to 91% and in disease-free survival (DFS) from 100% to 95.5% for the NO-PORT and PORT group, respectively. In our study, the cN0 pN+ patients had a higher degree of DFS compared to the cN+.

Validated Prognostic Nomograms for Patients With Parotid Carcinoma Predicting 2- and 5-Year Tumor Recurrence-Free Interval Probability

Introduction: Salivary gland malignancies are rare tumors with a heterogenous histological and clinical appearance. Previously, we identified multiple prognostic factors in patients with parotid cancer and developed prognostic indices which have repeatedly been validated internationally, demonstrating their general applicability and lasting relevance. Recently, nomograms gained popularity as a prognostic tool. Thus, in this research we aimed to construct nomograms based on our previous validated prognostic models.

Material and Methods: Nomograms were constructed using the previously reported dataset of 168 patients with parotid cancer which was used to develop pre- and postoperative prognostic scores, PS1 and PS2, respectively. Concordance indices for PS1 and PS2 were previously estimated at 0.74 and 0.71, respectively, and are in line with other, widely accepted oncological nomograms.

Results: Pre- and postoperative nomograms predicting 2- and 5-year tumor recurrence-free survival probability are presented. All previously multivariately identified and validated prognostic factors, are incorporated (T size, N classification, pain, age at diagnosis, skin invasion, facial nerve dysfunction, perineural growth, and positive surgical margins). Examples of clinical application and interpretation are given.

Conclusions: The presented prognostic nomograms for predicting 2- and 5-year tumor recurrence-free probability in patients with parotid cancer are powerful, user-friendly, visual tools and are based on internationally validated prognostic indices. They allow for a reliable prognostic assessment and result in a more individualized estimate of the risk for recurrence than the prognostic grouping based on PS1 and PS2. This facilitates assigning trial-patients to risk groups, and may assist in therapeutic decision making and determining appropriate follow-up intervals in clinical practice.

Neck involvement and disease recurrence in adenoid cystic carcinoma of the minor salivary glands: the role of surgery in primary and progressive disease

The aim of this study was to analyse the rates of metastatic events and clinical outcomes of patients with adenoid cystic carcinoma (ACC) of the minor salivary glands and to critically evaluate the role of surgical therapy. A retrospective cohort study was designed including all patients with ACC of the oral minor salivary glands treated in the study department during the years 2010-2017. Relevant clinicopathological data were analysed to determine factors with an impact on overall survival (OS) and progression-free survival (PFS). Forty-one patients with primary ACC of the oral cavity and the oropharynx were included. Cervical metastases were found in 14 patients (34.1%) and were shown to have a significant negative impact on OS (P=0.009) and PFS (P=0.03). Sixteen patients developed disease recurrence during follow-up (39.0%) and most patients exhibited local disease recurrence with or without regional or distant metastases (14/16, 87.5%). Local recurrence was treated successfully with surgery in five cases. We recommend surgical therapy for patients with ACC of the minor salivary glands, including elective neck dissection and microvascular reconstruction, to optimize the planning of adjuvant therapy.

Head and neck robotic surgery combined with sentinel lymph node biopsy. Fascinating, but feasible?

Robotic approaches and sentinel lymph node (SLN) biopsy are both strategies that evolved driven by the need to reduce impact of head and neck oncological surgery in terms of operative timing, morbidity, hospitalization time, and aesthetic results. A comprehensive review of the scientific literature was performed on PubMed, Embase, ResearchGate, Cochrane, and CENTRAL electronic databases with the aim to discuss the role that these two approaches can play together in the management of head and neck cancers (HNCs) of various sites. Dedicated publications on the combined robotics and SLN biopsy approaches resulted, up to now very limited, while their separated application in non-shared fields is gaining strength. However, the possibility to implement and combine technologies to minimize sequelae of head and neck surgery is an interesting and evolving topic.

Clinical-pathological prognostic factors and treatment failure patterns in T1-2 high-grade parotid gland cancer

OBJECTIVES

The purpose of this study was to evaluate the treatment outcomes of patients with T1-2, high-grade parotid cancer, and to analyze the prognostic factors and treatment failure patterns.

MATERIALS AND METHODS

Of the 101 patients who were diagnosed with high-grade parotid cancer from March 2003 to December 2018, a total of 39 males and 23 females who had T1-2 tumor were enrolled in this study.

RESULTS

The average follow-up period of patients in this study was 63.9 months. The 5-year overall survival rate was 73.0%, and the 5-year disease-free survival rate was 57.6%. Thirty-nine patients underwent less-than-total parotidectomies, and the remaining 23 patients underwent total parotidectomies. After surgery, 50 patients received adjuvant treatment. During the study, 25 recurrences were documented, including nine local recurrences and 16 distant metastases. The average time period between the end of initial treatment and disease relapse was 17.0 months. A total of 16 patients succumbed to disease progression. Multivariate Cox proportional regression analysis showed that lymphovascular invasion (LVI) was an independent prognostic factor affecting disease recurrence and patient deaths. Among various factors, LVI and lymph node (LN) metastasis showed statistically significant correlations with distant metastasis.

CONCLUSION

Although we achieved favorable therapeutic results using standard treatments in selected patients, T1-2 high-grade parotid cancers generally have poor prognosis. Distant metastases that occur during follow-up are a major factor in treatment failure and LVI and LN metastasis are significantly associated with distant metastasis.

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.

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.

A Preliminary Study of CT Texture Analysis for Characterizing Epithelial Tumors of the Parotid Gland

Objective

The aim of this study was to explore and validate the diagnostic performance of whole-volume CT texture features in differentiating the common benign and malignant epithelial tumors of the parotid gland.

Materials and Methods

Contrast-enhanced CT images of 83 patients with common benign and malignant epithelial tumors of the parotid gland confirmed by histopathology were retrospectively analyzed, including 50 patients with pleomorphic adenoma (PA) and 33 patients with malignant epithelial tumors. Quantitative texture features of tumors were extracted from CT images of arterial phase. The diagnostic performance of texture features was evaluated via receiver operating characteristic (ROC) curve and area under ROC curve (AUC). The specificity and sensitivity were respectively discussed by the maximum Youden’s index.

Results

All the texture features were subject to normal distribution and homoscedasticity. Energy, mean, correlation, and sum entropy of epithelial malignancy group were significantly higher than those of PA group (P<0.05). There were no statistically significant differences between PA group and epithelial malignancy group in uniformity, entropy, skewness, kurtosis, contrast, and difference entropy (P>0.05). The AUC of each texture feature and joint diagnostic model was 0.887 (energy), 0.734 (mean), 0.739 (correlation), 0.623 (sum entropy), 0.888 (energy-mean), 0.883 (energy-correlation), 0.784 (mean-correlation). The diagnostic efficiency of energy-mean was the best. Based on the maximum Youden’s index, the specificity of energy-correlation was the highest (97%) and the sensitivity of energy was the highest (97%).

Conclusion

Energy, mean, correlation, and sum entropy can be the effective quantitative texture features to differentiate the benign and malignant epithelial tumors of the parotid gland. With higher AUC, energy and energy-mean are superior to other indexes or joint diagnostic models in differentiating the benign and malignant epithelial tumors of the parotid gland. CT texture analysis can be used as a noninvasive and valuable means of preoperative assessment of parotid epithelial tumors without additional cost to the patients.

Dual Coaptation of Facial Nerve Using Masseteric Branch of Trigeminal Nerve for Iatrogenic Facial Palsy: Preliminary Reports

OBJECTIVES

Immediate facial nerve substitution or graft technique has been used for the repair of facial nerve defects occurring as a result of tumour dissection. However, some patients report unsatisfactory outcomes, such as difficulty in maintaining resting or smiling symmetry, due to persistent flaccid facial palsy. Here we evaluated the functional outcomes of transferring the masseteric branch of the trigeminal nerve to the facial nerve adjunct to facial nerve graft.

METHODS

We reviewed the medical records of seven patients who underwent facial reanimation surgery between 2014 and 2016. The patients were divided into two groups according to the type of facial reanimation surgery: group A, masseteric nerve innervation with interposition graft; group B, interposition graft only. The postoperative resting symmetry and dynamic movement were compared.

RESULTS

Facial contraction was first observed in group A at 4 months and in group B at 7.3 months. Most of the patients achieved reliable resting symmetry; however, one patient in group B exhibited unsatisfactory facial weakness on the affected side. Group A patients showed better dynamic movement than group B patients. Eye closure, oral excursion and oral continence were better in group A than in group B patients. Smile symmetry in both groups was similar due to hyperkinetic movement in group A patients and flaccidity in group B patients.

CONCLUSIONS

Dual innervation of the masseteric branch of the trigeminal nerve improves the dynamic movement of paralysed facial muscles and shortens the recovery period in patients with iatrogenic facial palsy.

Management of clinically negative neck in salivary gland cancers - elective neck dissection, irradiation, or surveillance?

Aim of the study

To retrospectively assess treatment outcomes among patients treated for salivary gland cancers at our institution to determine which of the three most common treatment approaches - elective neck dissection (END), elective neck irradiation (ENI), or observation - provide the best results.

Material and methods

A total of 122 patients were identified who had undergone primary surgery for SGC followed by END, ENI, or observation. The patients were classified into three groups according to the treatment approach used to manage the neck: END, ENI, or observation. The main outcome measures were disease-free survival (DFS) and overall survival (OS). We also sought to identify the risk factors potentially associated with neck metastasis and treatment failure.

Results

106 patients met all inclusion criteria. Of these 106 patients, 27 (25.7%) underwent END, 17 (16.0%) underwent ENI, and 62 (58.5%) observation. There were no statistically significant differences between the three groups in any of the following variables: advanced age (> 70); presence of locally advanced disease (T3 or T4); perineural invasion; lymphovascular invasion; and primary tumour location. Treatment failure was higher (non-significantly) in the END group (25.9%) vs. the observation (21.0%) and ENI (11.8%) groups. No differences (Kaplan-Meir curves) were observed among the three groups in terms of DFS or OS.

Conclusions

Our results show that elective neck dissection does not appear to provide any benefit to patients treated for malignant salivary gland cancer. Importantly, these findings contradict most of the currently available research. However, due to methodological differences among the available studies, our findings cannot be compared directly to other studies.

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.

A nomogram to estimate the risk of developing distant metastases in parotid cancer

BACKGROUND

Parotid cancer (PC) is a heterogeneous group of malignant tumors whose management mainly focuses on locoregional control. However, distant metastases (DM) can represent the most common cause of treatment failure. We have defined the predictors and developed a model that can predict a single patient's risk to develop DM.

METHODS

We have analyzed our institutional database of 259 patients with PC and use it to develop a nomogram. C-index and calibration curves were used to assess performance of our model.

RESULTS

DM appeared in 18.9% of patients. Age, cT, pN, perineural invasion, and adenoid cystic carcinoma were significantly associated with distant failure.

CONCLUSIONS

We here present the first model to identify patients with PC at high risk of DM. Such tool can be of great value in managing these rare cancers in terms of a more precise prognosis and follow-up while waiting for better systemic therapies to come in the future.

Anatomic extent of lymph node metastases as an independent prognosticator in node-positive major salivary gland carcinoma: A study of the US SEER database and a Chinese multicenter cohort

BACKGROUND

We aimed to explore whether the anatomic extent of lymph node metastases (AE-LNM) could independently predict prognosis of node-positive major salivary gland carcinoma (MaSGC).

METHODS

A total of 376 pathologically node-positive MaSGC patients were identified from the Surveillance, Epidemiology and End Results database and constituted the training cohort. Using the X-Tile program, these patients were divided into three groups based on AE-LNM degrees. Discrimination of overall survival (OS) and disease-specific survival (DSS) was evaluated and compared with the 8th American Joint Committee on Cancer (AJCC) pN classification. The results were externally validated by 220 patients in a Chinese multicenter cohort (Validation cohort).

RESULTS

Using the training cohort, AE-LNM was divided into Extent 1 (spread to parotid LNs or level I), Extent 2 (spread to level II-IV) and Extent 3 (spread to level V or bilateral LNs or rare LNs). Regarding both OS and DSS, the AE-LNM model revealed clear separation of survival curves, while the pN classification failed to discriminate the prognosis of pN1 and pN2 patients. When we incorporated both the AE-LNM model and AJCC pN classification into the same multivariate Cox analyses, AE-LNM was still an independent prognostic factor, while the AJCC pN classification lost its significance. These results were externally validated by the validation cohort.

CONCLUSION

AE-LNM is an independent nodal prognosticator for node-positive MaSGC and may have improved discriminative ability over the current AJCC pN classification. Integration of anatomic extent of LNM into the current AJCC N classification could be considered.