Adenoid cystic carcinoma of the skull base

Adenoid Cystic Carcinoma (ACC) Infiltrating the Skull Base: A Systematic Review of Clinical Characteristics and Management Strategies

BACKGROUND/AIM

To systematically review the patient characteristics and management approaches of adenoid cystic carcinoma (ACC) infiltrating the skull base.

MATERIALS AND METHODS

According to PRISMA guidelines, PubMed, Scopus, and Cochrane were searched to retrieve studies reporting management protocols and survival outcomes of patients with skull base ACCs. Patient characteristics, management strategies, and outcomes were investigated.

RESULTS

The review encompassed 17 studies involving 171 patients, with a female predominance (57.9%) and a mean age of 49±7.12 years. ACCs mostly infiltrated the paranasal sinus (22.2%), cavernous sinus (8.8%), and nasopharynx (7.1%). Perineural invasion was reported in 6.4% of cases. Facial pain, nasal obstruction, and facial paresthesia were the most common symptoms. Surgical resection (45.6%) was favored over biopsy (12.2%). Employing the free flap technique (4.7%), surgical reconstruction of the bony defect after resection was performed using abdominal and anterior thigh muscle grafts in 1.8% of patients each. As adjuvant management, 22.8% of cases had radiotherapy and 14.6% received chemotherapy. Recurrence of skull base ACCs occurred in 26.9% of cases during a mean follow up-time of 30.8±1.8 months.

CONCLUSION

Skull base ACCs pose a surgical challenge mainly due to their proximity to critical neurovascular structures and aggressive behavior. Surgical resection and radiotherapy are shown to be safe and effective treatment modalities. The dismal prognosis and limited data on non-surgical strategies highlight the need for further evaluation of the current management paradigm and upraising innovative therapies to improve patient mortality and quality of life.

Cystic sellar salivary gland-like lesions

Introduction: Cystic sellar salivary gland-like lesions (CSSLs) are exceedingly rare, with fewer than a dozen case reports. They contain amorphous colloid identical to Rathke cleft cyst contents, but the cyst wall additionally shows cohesive aggregates of benign salivary glands. We report three new examples. Materials and methods: Two cases were seen at University of Colorado Denver and one at Memorial Sloan Kettering (MSK). Molecular testing was attempted on two of three. Results: Case 1 is a 20-year-old female who presented with panhypopituitarism and was found to have a suprasellar mass that proved to be a CSSL. She received no postoperative adjuvant therapy, but recurrence of headaches and blurred vision 2 years later prompted return to medical attention. A much smaller local cyst recurrence was now accompanied by a thickened, bulbous infundibular stalk. Second resection yielded a gliotic infundibular stalk and amorphous mucin, but no residual salivary-like glands. She is without further recurrence on 6-year follow-up. Case 2 is a 29-year-old female with headache; while seen initially at a tertiary care center, diagnosis was only made after consultation at MSK. Case 3 is 68-year-old female who had originally presented with apoplexy to an outside hospital 7 years prior to surgery and diagnosis. Molecular testing was uninformative on case 1 and negative for mutations or fusions on case 3. Conclusion: Few pathologists or neuropathologists have encountered CSSLs in their practices; case 1 produced recurrence and significant infundibular stalk damage, and case 3 originally manifested apoplexy, features not previously reported.

The endoscopic endonasal approach for sinonasal and nasopharyngeal adenoid cystic carcinoma

OBJECTIVE

To determine factors affecting outcomes for patients with sinonasal and nasopharyngeal adenoid cystic carcinoma (SNACC) treated using the endoscopic endonasal approach (EEA) with preservation of key structures followed by adjuvant radiotherapy (RT).

METHOD

Retrospective case series of 30 patients treated at the University of Pittsburgh between 2000 and 2014. Hospital records were reviewed for clinical and pathologic data. Outcome measures included overall survival (OS), disease-free survival (DFS), local recurrence-free survival (LRFS) and distant metastasis-free survival (DMFS) rates.

RESULTS

The majority of patients had T4a and T4b disease (23.3%, and 63.3%). Microscopically positive margins were present in 21 patients (63.6%). Positive margins were present in nine patients (30.0%). The mean and median follow-up were 3.97 and 3.29 years. Five-year OS, DFS, LRFS, and DMFS were 62.66%, 58.45%, 87.54%, and 65.26%. High-/intermediate-grade tumors had worse DFS (P = .023), and LRFS (P = .026) (HR = 4.837, 95% CI, 1.181-19.812). No factors were associated with significantly worse DMFS. No patient suffered CSF leak, optic nerve, or internal carotid injury. The mean and median length of hospital stay was 4.1 days and 2.0 days (range: 0-32 days).

CONCLUSION

Organ-preserving EEA with adjuvant RT for low-grade SNACC offers 5-year survival similar to that reported by other studies, which include radical, open skull base surgery. Patients with high-grade disease do poorly and may benefit from novel treatment strategies. For low-grade disease, organ-preserving EEA with RT may be the best option, offering a balance of survival, quality of life, and decreased morbidity for patients with this difficult-to-cure disease.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:1414-1421, 2020.

ICAR: endoscopic skull-base surgery

BACKGROUND

Endoscopic skull-base surgery (ESBS) is employed in the management of diverse skull-base pathologies. Paralleling the increased utilization of ESBS, the literature in this field has expanded rapidly. However, the rarity of these diseases, the inherent challenges of surgical studies, and the continued learning curve in ESBS have resulted in significant variability in the quality of the literature. To consolidate and critically appraise the available literature, experts in skull-base surgery have produced the International Consensus Statement on Endoscopic Skull-Base Surgery (ICAR:ESBS).

METHODS

Using previously described methodology, topics spanning the breadth of ESBS were identified and assigned a literature review, evidence-based review or evidence-based review with recommendations format. Subsequently, each topic was written and then reviewed by skull-base surgeons in both neurosurgery and otolaryngology. Following this iterative review process, the ICAR:ESBS document was synthesized and reviewed by all authors for consensus.

RESULTS

The ICAR:ESBS document addresses the role of ESBS in primary cerebrospinal fluid (CSF) rhinorrhea, intradural tumors, benign skull-base and orbital pathology, sinonasal malignancies, and clival lesions. Additionally, specific challenges in ESBS including endoscopic reconstruction and complication management were evaluated.

CONCLUSION

A critical review of the literature in ESBS demonstrates at least the equivalency of ESBS with alternative approaches in pathologies such as CSF rhinorrhea and pituitary adenoma as well as improved reconstructive techniques in reducing CSF leaks. Evidence-based recommendations are limited in other pathologies and these significant knowledge gaps call upon the skull-base community to embrace these opportunities and collaboratively address these shortcomings.

[Malignant tumors of the skull base]

Malignant skull base tumors consist of a heterogeneous group of malignancies that can be divided into primary and secondary (metastatic) skull base tumors. In addition, according their anatomical location, they can be further divided into tumors of the anterior, middle, or posterior cranial fossa. Although malignant skull base tumors do not rigorously respect anatomical borders, their anatomical occurrence can potentially be helpful for possible differential diagnosis. This article is focused on the most common malignant tumors of the skull base and their imaging and clinical presentations.

The Safety and Accuracy of Surgical Navigation Technology in the Treatment of Lesions Involving the Skull Base

OBJECTIVE

As compared with the normal anatomy, structures of the skull base and its surroundings have been dramatically altered of the lesion near the skull base. How to remove the lesion at the skull base was mainly depending on surgeon's personal experience during past years. In this study, the authors explored the safety and accuracy of the surgical navigation system in resecting lesions near the skull base.

METHODS

The surgical cases consisted of 15 patients who underwent surgery involving the skull base with the using of surgical navigation technology. Five patients had adenoid cystic carcinoma at minor salivary glands of the palate extending to the skull base and 10 patients were suffered from bony ankylosis of temporomandibular joint. After the system converted patient's computed tomography scans into three-dimensional reconstructive images, preoperative planning and simulation of the operation process could be made by surgeons. During the operation, the virtual images were matched with the patient through individual registration. The system provided surgeon with feedback about the operation on the screen instantly with moving the navigated pointer.

RESULTS

The application of surgical navigation system was safe and reliable for resecting the ankylotic bone and identifying the extent of tumors resection near the skull base. No complications including cerebrospinal fluid leak, cranial nerve injuries, severe bleeding happened to those patients.

CONCLUSIONS

Given the safety and accuracy of the surgical navigation system, surgery near the skull base appeared to be an ideal field for using with its complex anatomy.

Clinical Outcomes and Prognostic Factors of Adenoid Cystic Carcinoma of the Head and Neck

BACKGROUND

Adenoid cystic carcinoma (ACC) is a salivary gland malignancy with unpredictable growth and poorly understood prognostic factors.

PATIENTS AND METHODS

A database search of patients treated at a single Institution was used to identify patients with histologically-confirmed ACC. Patient, tumor, and treatment characteristics were examined via review of medical records.

RESULTS

Overall survival of 70 patients identified at 5, 10, and 15 years was 80.4%, 61.3%, and 29.4%, respectively. Disease recurrence was seen in 31.9%; of these, 72.7% developed distant metastasis. Older age, higher stage, skull base involvement, positive margins, and metastatic disease, but not local recurrence, predicted a worse overall survival. Higher stage and skull base disease were also associated with shorter disease-free survival. While lung metastasis was the most common, vertebral metastasis was associated with poorer survival.

CONCLUSION

Disease stage, positive margins, skull base involvement, perineural invasion, time to recurrence, and location of metastasis, but not nodal involvement, could serve as poor prognostic factors in ACC.

Sinonasal adenoid cystic carcinoma: Treatment outcomes and association with human papillomavirus

BACKGROUND

The purpose of this study was to review long-term outcomes of sinonasal adenoid cystic carcinoma (ACC) and to clarify its association with human papillomavirus (HPV).

METHODS

The medical records of 23 patients with sinonasal ACC treated with primary surgical resection between 1998 and 2013 were reviewed. Tissue specimens were available for 17 patients. The p16 testing was performed using immunohistochemistry (IHC), and HPV infection was determined using quantitative polymerase chain reaction (PCR) with primers targeting the E6/E7 region.

RESULTS

Two of the 17 samples showed strong and diffuse p16 staining, whereas the remaining 15 cases showed p16-positivity isolated to the luminal cells. Only one of the p16-positive cases was positive for HPV. The 5-year local failure, disease-free survival (DFS), and overall survival (OS) were 51%, 52%, and 62%, respectively.

CONCLUSION

Local failures are common with advanced sinonasal ACC, and the association of HPV with true sinonasal ACC is low.

Adenoid cystic carcinoma of the skull base: results with an aggressive multidisciplinary approach

OBJECT

Adenoid cystic carcinoma (ACC) is a locally aggressive tumor of salivary gland origin. Little data exist to guide treatment when this tumor extends to involve the structures of the skull base.

METHODS

Fifty-one patients with a diagnosis of ACC affecting the skull base were identified from a prospective database at MD Anderson Cancer Center (from 1992 to 2010).

RESULTS

Median follow-up for study patients was 6.75 years. The 5- and 10-year overall survival (OS) rates were 78% and 50%, respectively. Sixty-six percent of patients had progression of their disease. The 5- and 10-year progression-free survival (PFS) rates were 46.7% and 21.0%, respectively. Gross-total resection was achieved in 75% of patients, with 49% having microscopically negative margins at the time of first operation. On univariate analysis, resections with microscopically negative margins were associated with a significant OS advantage (20.1 ± 3.3 years) compared with resections that left residual disease, even if microscopic (10.3 ± 1.6 years, p = 0.035). In patients who underwent reoperation, the effect persisted, with improved OS in those with negative margins (21.4 ± 0.0 vs 16.7 ± 4.0 years, p = 0.06). The use of adjuvant radiotherapy was associated with an OS advantage (16.2 ± 2.5 vs 5.5 ± 2.2 years, p = 0.03) at initial diagnosis and improved PFS (7.8 ± 1.0 vs 2.1 ± 0.62 years, p = 0.005), whereas repeat irradiation provided no benefit. The use of adjuvant chemotherapy at diagnosis or at recurrence was not associated with any significant advantage. Multivariate analysis revealed margin-negative resection at initial operation and at recurrence retained OS significance, even after controlling for age, radiation therapy, and T stage.

CONCLUSIONS

ACC of the skull base is best treated with a multidisciplinary approach aimed at maximal, safe resection. Adjuvant radiotherapy should be offered, whereas chemotherapy does not confer benefit.

Sinonasal tract and nasopharyngeal adenoid cystic carcinoma: a clinicopathologic and immunophenotypic study of 86 cases

Primary sinonasal tract and nasopharyngeal adenoid cystic carcinomas (STACC) are uncommon tumors that are frequently misclassified, resulting in inappropriate clinical management. Eighty-six cases of STACC included 45 females and 41 males, aged 12-91 years (mean 54.4 years). Patients presented most frequently with obstructive symptoms (n = 54), followed by epistaxis (n = 23), auditory symptoms (n = 12), nerve symptoms (n = 11), nasal discharge (n = 11), and/or visual symptoms (n = 10), present for a mean of 18.2 months. The tumors involved the nasal cavity alone (n = 25), nasopharynx alone (n = 13), maxillary sinus alone (n = 4), or a combination of the nasal cavity and paranasal sinuses (n = 44), with a mean size of 3.7 cm. Patients presented equally between low and high stage disease: stage I and II (n = 42) or stage III and IV (n = 44) disease. Histologically, the tumors were invasive (bone: n = 66; neural: n = 47; lymphovascular: n = 33), composed of a variety of growth patterns, including cribriform (n = 33), tubular (n = 16), and solid (n = 9), although frequently a combination of these patterns was seen within a single tumor. Pleomorphism was mild with an intermediate N:C ratio in cells containing hyperchromatic nuclei. Reduplicated basement membrane and glycosaminoglycan material was commonly seen. Necrosis (n = 16) and atypical mitotic figures (n = 11) were infrequently present. Pleomorphic adenoma was present in 9 cases; de-differentiation was seen in two patients. Immunohistochemical studies showed positive reactions for pan-cytokeratin, CK7, CK5/6, CAM5.2, and EMA, with myoepithelial reactivity with SMA, p63, calponin, S100 protein and SMMHC. CD117, CEA, GFAP and p16 were variably present. CK20 and HR HPV were negative. STACC needs to be considered in the differential diagnosis of most sinonasal malignancies, particularly poorly differentiated carcinoma, olfactory neuroblastoma and pleomorphic adenoma. Surgery (n = 82), often accompanied by radiation therapy (n = 36), was generally employed. A majority of patients developed a recurrence (n = 52) 2-144 months after initial presentation. Overall mean follow-up was 19.4 years (range 0.4-37.5 years): 46 patients died with disease (mean 6.4 years); 5 were alive with disease (mean 5.4 years), and 35 patients were either alive or had died of unrelated causes (mean 16.3 years). ACC of the SNT is uncommon. Recurrences are common. The following parameters, when present, suggest an increased incidence of either recurrence or dying with disease: mixed site of involvement, high stage disease (stage IV), skull base involvement, tumor recurrence, a solid histology, perineural invasion, bone invasion, and lymphovascular invasion.

Sinonasal Adenoid Cystic Carcinoma

Objective

This study reviews the published outcomes related to sinonasal adenoid cystic carcinoma (SNACC). Clinical presentation, radiographic diagnosis, pathology, treatment, and management outcomes of this uncommon disease are reported.

Data Sources

PubMed database.

Methods

A systematic review of studies for SNACC from 1960 to 2012 was conducted. A PubMed search for articles related to SNACC, along with bibliographies of those articles, was performed. Articles were examined for both individual patient data (IPD) and aggregate patient data (APD) that reported survivability. Demographics, disease site and spread, treatment strategies, follow-up, outcome, and survival were described for IPD, and a meta-analysis for survival rates was performed for APD.

Results

A total of 55 journal articles were included. Individual patient data were reported in 39 journal articles, comprising a total of 88 cases of SNACC. Sixteen articles, totaling 366 patients that reported aggregate 5-year survivorship pertaining to SNACC, were also included. Average follow-up in the IPD was 51.2 months (range, 1-198 months), and 5-year survivorship was 63.5%. In the studies reviewed, surgery followed by postoperative radiotherapy was the most common therapy used and resulted in the highest percentage of survivors. Aggregate patient data meta-analysis revealed a 5-year survival rate of 62.5%.

Conclusion

This study contains the largest pool of SNACC patients to date. The data suggest that SNACC has a poor overall prognosis. It also suggests that surgery with postoperative radiotherapy is the most commonly used and may possibly be the most effective therapy.

A case of adenoid cystic carcinoma presenting as Garcin's syndrome without mass formation

Adenoid cystic carcinoma (ACC) is a malignant neoplasm that commonly arises in the major or minor salivary gland and usually forms mass lesions. Here, we report a case of ACC involving a 56-year-old man, who displayed right multiple cranial nerve palsies with ipsilateral severe facial pain but not any mass formation. Right submaxillary gland biopsy after repeated challenges at last revealed the primary focus of ACC with perineural invasion and without lymph node metastasis. The neurological manifestations were considered to be attributed to the perineural spread of ACC. It is extremely rare for ACC to show Garcin's syndrome without mass formation.

Perineural tumor spread in malignant head and neck tumors

Perineural tumor spread (PNS) of head and neck malignancies is a course of disease in which tumor metastasizes along the endoneurium or perineurium. Perineural tumor spread is a potentially devastating complication of head and neck cancer and has a high impact on the therapeutical management and overall prognosis. Imaging plays an important role in the detection of this condition, especially in view of a large number of clinically asymptomatic patients with PNS. Magnetic resonance imaging is the modality of choice in the assessment of PNS because of its multiplanar capability and its superior soft-tissue contrast. Knowledge of normal cranial nerve anatomy and the imaging appearance of perineural tumor extension is imperative in the evaluation of PNS which represents a special challenge in head and neck radiology.

Adenoid cystic carcinoma of the head and neck: a review

PURPOSE OF REVIEW

This purpose of this article is to review and provide an update of current publications on the evaluation and management of adenoid cystic carcinoma.

RECENT FINDINGS

Adenoid cystic carcinoma is an uncommon salivary gland malignancy that presents insidiously and is generally advanced when diagnosed. Current effective treatment modalities include surgery and irradiation, but locoregional recurrences are frequent and may present as early as 2 years. Patients survive with recurrent and metastatic disease for several years despite not being offered any treatment. Molecular analysis of the tumors is being undertaken, with optimistic results capable of selecting high-risk patients who may benefit from adjuvant treatment such as chemotherapy

SUMMARY

Little progress has been made in advancing "curative" treatment of adenoid cystic carcinoma of the head and neck. The disease is said to have a fatal outcome. The time is now opportune for a multicenter, randomized, controlled trial to identify patients who would benefit from adjuvant radiotherapy and/or chemotherapy in the control of locoregional recurrences and the prevention of distant metastases.

Management of nasopharyngeal salivary gland malignancy

OBJECTIVE

The objective of this study was to evaluate the oncological outcome and complication rate following surgical treatment of nasopharyngeal salivary gland malignancy.

STUDY DESIGN

Retrospective case review at tertiary care skull base center.

METHODS

Pertinent medical records were reviewed from 23 patients presenting with minor salivary gland malignancy. Clinical presentation, prior treatment, histological type and grade, clinical stage, details of surgical treatment, and postoperative adjuvant radiation therapy were studied. Survival and recurrence data were analyzed using the Kaplan-Meier and Cox proportional hazards methods.

RESULTS

Histological types included 11 adenoid cystic carcinomas, 8 mucoepidermoid carcinomas, and 4 cases of adenocarcinoma not otherwise specified. All patients underwent primary surgical resection, and the lateral infratemporal middle fossa approach was used in 20 patients. Prior radiation therapy had been administered in 6 patients who presented for treatment of recurrent disease, and the remaining 17 patients underwent planned postoperative radiation therapy. Elective neck dissection was undertaken in 15 patients, and occult neck disease was present in 47%. Disease specific survival was 67% at 5 years and 48% at 10 years. High-grade tumors had a significantly poorer outcome (P =.035) with a relative risk of 4.6 compared with low-grade disease. Local control was seen to be 77% at 5 years.

CONCLUSIONS

Planned combined surgery and radiation therapy achieves survival outcomes and recurrence rates in nasopharyngeal salivary gland malignancy comparable to results reported using the same treatment for minor salivary gland tumors cancer originating elsewhere in the head and neck. Because of the high rate of occult neck metastases, we recommend elective neck dissection as part of the surgical treatment with this disease entity. The lateral infratemporal middle fossa approach provides safe and adequate access to resect the vast majority of these tumors with acceptable complication rates. A reliable form of vascularized reconstruction is necessary to prevent serious postoperative complications, and we currently prefer the gastro-omental free flap.