Management of salivary gland malignancies in the pediatric population:

Long-term follow-up and prognostic analysis of parotid tumors in children and adolescents

Objectives

The objective of this study is to summarize the clinical characteristics, treatment, and prognosis of parotid tumors in children and adolescents.

Methods

Fifty-three children and adolescents diagnosed with parotid gland tumors were included. Survival was evaluated using the Kaplan-Meier method. Log-rank test and multivariate analysis were used to analyze the association between clinical factors and recurrence.

Results

Of the 53 patients, 30 cases were benign and 23 cases were malignant. All patients underwent surgery. Patients with malignant tumors with high-risk factors received radiotherapy or chemotherapy. The median follow-up time was 61 months. Of these, 1 patient with benign tumor and 5 patients with malignant tumors recurred. Of the patients with malignant tumors, 2 developed distant metastases and 2 died. The 5-year overall survival (OS) and 5-year locoregional recurrence-free survival (LRFS) rates for benign tumors were 100.0% and 92.9%, respectively, whereas the 5-year OS and 5-year LRFS rates for malignant tumors were 94.4% and 72.5%, respectively. The log-rank univariate test showed that tumor size >3.5 cm (p = .056), distant metastasis (p = .056), and stage III and IV (p = .032) were associated with recurrence. However, multivariate analysis did not show the above factors to be independent prognostic factors for LRFS.

Conclusion

Surgery for benign tumors depends on the location and size. Surgery for malignant parotid tumors depends mainly on the stage, grade, pathological type, and recurrence. Prophylactic lymph node dissection is required for high-grade tumors. Radiotherapy or chemotherapy for children needs more research. Both benign and malignant tumors have high survival rates after active treatment.

Level of evidence

Level 2.

Pediatric primary salivary gland tumors

OBJECTIVES

To characterize the presentation and treatment of children presenting with primary salivary gland neoplasms.

METHODS

A retrospective review of primary salivary tumor patients presenting to Children's Hospital Colorado between January 2000 and August 2020.

RESULTS

Fifty children were identified with primary salivary gland tumors, comprising of 39 (78 %) benign and 11 (22 %) malignant lesions. Pleomorphic adenoma was the most common benign tumor (36/39, 92 %), while acinic cell carcinoma was the most common malignancy (7/11, 64 %). The parotid gland was the most common site, followed by the submandibular gland (66 % vs. 34 %). No tumors were found in the sublingual glands. Benign neoplasms accounted for 70 % of parotid lesions and 94 % of submandibular tumors. No significant differences in age (13.6 years, SD 4 vs. 13.0 years, SD 4.3) were noted between patients with benign and malignant disease, but tumors in females were more frequently malignant (M:F 1:1.3 vs. 1:2.7 for benign and malignant tumors, respectively). Neck dissection and/or facial nerve sacrifice were required in 27 % (3/11) and 9.1 % (1/11) of malignancies, respectively. Local recurrence was observed in 7.7 % (3/39) of benign cases and 9.1 % (1/11) of malignant cases. No salivary malignancies required chemotherapy, though one patient with neurofibromatosis received imatinib prior to resection. Two patients with locoregional malignancy received adjunctive radiation. The average duration of follow up for benign and malignant disease were 12.6 ± 25 and 45.1 ± 32 months, respectively.

CONCLUSIONS

This study presents one of the larger single institutional experiences of pediatric primary salivary neoplasms in the past 20 years, identifying pleomorphic adenoma and acinic cell carcinoma as the most common benign and malignant etiologies, respectively. While this review found most neoplasms presented as a localized mass effectively managed with conservative surgical resection, aggressive tumors required multidisciplinary care.

Surgical management of pediatric salivary malignant tumors-A single-center cohort study

BACKGROUND

The purpose of this study was to report incidence, clinicopathologic behavior, management, and outcome of pediatric patients treated surgically for salivary gland (SG) malignancies.

METHODS

Patients who underwent surgery for SG malignancies from 1985 to 2015 were identified. Clinical, pathological, treatment and outcomes data were collected. Disease-specific survival (DSS), recurrence-free survival (RFS), and overall survival (OS) were calculated using Kaplan-Meier method.

RESULTS

Twenty-eight pediatric patients were included. The most common histopathological types were mucoepidermoid (n = 18, 64.3%), acinic cell (n = 7, 25.0%), adenoid cystic (n = 2, 7.1%), and adenocarcinoma (n = 1, 3.6%). Surgical approach varied and ranged from superficial parotidectomy (n = 11, 39.3%) to partial maxillectomy (n = 6, 21.4%). Nine patients (32%) required postoperative radiotherapy. DSS, OS, and RFS probability at 5 years were 96.4%, 96.4%, and 89.3%, respectively.

CONCLUSION

Pediatric SG malignancies are rare and have favorable outcome at 5 years. Larger, multi-institutional studies are required to better understand the natural history of these rare tumors.

Pediatric Salivary Gland Disease

Salivary gland disease in the pediatric population is rare, yet it encompasses a wide spectrum of disease. It is estimated that 4.3% of salivary gland disease occurs in the pediatric population, with most classified as nonneoplastic. Further extrapolation reveals that 5% of salivary gland neoplastic diseases occur in patients younger than 20 years. Moreover, salivary gland tumors represent 1% of all head and neck tumors across all ages. Regardless, clinicians across all fields should be familiar with the workup of various pediatric salivary gland diseases and appropriate referral to a pediatric otolaryngologist.

Fine-Needle Aspiration Biopsy of Pediatric Salivary Gland Tumors: Analysis of Patient Tolerability, Sedation Requirement, and Procedural Complication

OBJECTIVE

Fine-needle aspiration (FNA) biopsy is the standard diagnostic tool recommended by consensus management guidelines for preoperative evaluation of salivary gland tumors in adults. However, its utility in the pediatric population remains debated due to a paucity of data and inherited challenges of pediatric management (patient cooperation, the need for sedation, and procedural complications).

METHODS

Consecutive series of 92 FNA biopsies of pediatric salivary gland lesions with available procedural data were included for retrospective analysis. Patient demographics, procedural characteristics, and complications were assessed.

RESULTS

Sixty-three patients (68%) tolerated FNA without sedation. Sedation need was significantly associated with younger age, concurrent non-FNA procedure requiring sedation, ultrasound guidance, interventional radiologist as the proceduralist, and radiology suite as the facility setting. The sedation rates for children, and early, middle, and late adolescents were 69%, 32%, 12%, and 10%, respectively, with an optimal cutoff point of ≤12 years for age derived from receiver operating characteristic curve analysis. No significant procedural complications were observed. Sedation did not provide significantly better diagnostic yield.

CONCLUSION

FNA biopsy of salivary gland tumors is safe, well tolerated by the pediatric population, and can be effectively performed in an outpatient setting without sedation in most cases. FNA biopsy is a useful tool in the preoperative management of pediatric patients with salivary gland tumors.

Application of the Milan System for Reporting Pediatric Salivary Gland Cytopathology: Analysis of histologic follow-up, risk of malignancy, and diagnostic accuracy

BACKGROUND

The diagnosis and management of salivary gland tumors in pediatric patients can be challenging. The utility of fine-needle aspiration (FNA) cytopathology and the performance of the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) in this age group have not been systematically assessed. The paucity of data has contributed to the controversial role of FNA cytopathology in the presurgical management of these patients.

METHODS

The authors retrospectively analyzed 104 pediatric salivary gland FNAs (2000-2020). A correlation with the available histopathologic follow-up (n = 54) was performed. The distribution percentages, the risk of neoplasm (RON), and the risk of malignancy (ROM) were assessed for each category of the MSRSGC.

RESULTS

The overall sensitivity, specificity, negative predictive value, and positive predictive value of pediatric salivary gland FNAs were 80%, 97%, and 92%, respectively. The RON values for the nondiagnostic, nonneoplastic, atypia of undetermined significance, benign neoplasm, salivary gland neoplasm of uncertain malignant potential, suspicious for malignancy, and malignant categories were 60%, 11%, 100%, 100%, 100%, 100%, and 100%, respectively, whereas the ROM values were 0%, 11%, 100%, 6%, 67%, 100%, and 100%, respectively. The percentage of nonneoplastic FNAs was greater in comparison with the adult population (52% vs 8%). All neoplasms in patients aged 0 to 10 years were malignant, whereas benign neoplasms occurred only in patients aged ≥11 years; this supported an inverse correlation between age and malignancy rate in salivary gland neoplasms.

CONCLUSIONS

FNA cytopathology demonstrates excellent diagnostic performance in differentiating malignant and benign pediatric salivary gland lesions. The MSRSGC is a valuable tool for standardization of the reporting and preoperative risk stratification of these lesions.

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

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

Diagnosis and management of pediatric epithelial salivary gland malignancy

PURPOSE OF REVIEW

Salivary tumors are uncommon among children but are more likely to be malignant compared with adults. A lack of experience makes consensus in treatment elusive. Amidst recent publication of large institutional and national series, this review aims to discuss the epidemiology, diagnosis, investigation, and treatment for pediatric epithelial salivary malignancies.

RECENT FINDINGS

Pediatric salivary malignancies are often low grade and carry a favorable prognosis. High-grade tumors portend an increased risk of recurrence and a decreased survival. Surgeons should strive for oncologic resection with clear margins and avoid enucleation and excisional biopsies. Overt nodal metastases require concurrent neck dissection, whereas elective neck dissections may be reserved for cases with high risk of occult disease, such as advanced stage and high-grade neoplasms. Adjuvant radiation should be considered in high-grade tumors.

SUMMARY

The paucity of high-level evidence clouds treatment decisions and further encourages pediatric salivary malignancies to be treated in an experienced center with a multidisciplinary approach.

Survival and characteristics of pediatric salivary gland cancer: A systematic review and meta-analysis

A systematic search of PubMed, EMBASE, and the Cochrane Library for studies from 2000 to 2017 including children aged 0-19 with salivary gland cancer was performed. In 19 studies, 749 children (median age of 14.2 years, female to male ratio of 1.4:1) were included; 72% had parotid tumors and 95% underwent surgery, of whom 65% had surgery alone and 24% with adjuvant radiotherapy. Low-grade and stage mucoepidermoid carcinoma were the most frequent cancer. The 5-year overall- and disease-free survival was 94% and 83%. Recurrence was observed in 20% at a median of 1.1 years from diagnosis.

Contemporary Management of Benign and Malignant Parotid Tumors

To report the standard of care, interesting new findings and controversies about the treatment of parotid tumors. Relevant and actual studies were searched in PubMed and reviewed for diagnostics, treatment and outcome of both benign and malignant tumors. Prospective trials are lacking due to rarity of the disease and high variety of tumor subtypes. The establishment of reliable non-invasive diagnostics tools for the differentiation between benign and malignant tumors is desirable. Prospective studies clarifying the association between different surgical techniques for benign parotid tumors and morbidity are needed. The role of adjuvant or definitive radiotherapy in securing loco-regional control and improving survival in malignant disease is established. Prospective clinical trials addressing the role of chemotherapy/molecular targeted therapy for parotid cancer are needed. An international consensus on the classification of parotid surgery techniques would facilitate the comparison of different trials. Such efforts should lead into a clinical guideline.

Pediatric salivary gland carcinomas: Diagnostic and therapeutic management

OBJECTIVES/HYPOTHESIS

To analyze clinical presentations, treatment modalities, and evolution of pediatric cases of salivary gland carcinomas to standardize care for these rare diseases.

STUDY DESIGN

Multicentric, retrospective study.

METHODS

We included in this retrospective study all children and adolescents (aged ≤18 years) treated from 1992 to 2012 in six pediatric centers in Paris, France. Pathological tumor specimens of these cases were reviewed.

RESULTS

Forty-three children were included (sex ratio male/female = 19/24, median age = 13 years). The parotid gland was the most common (37 cases) location for tumors. Histological subtypes were mucoepidermoid carcinomas (n = 20), acinic cell carcinomas (n = 14), and other (n = 9). Initial fine-needle aspiration was performed in 15 cases (33%), and was concordant to final diagnosis in three cases (20%). Primary surgery was performed in 42 patients, leading to a complete microscopic resection in 80%. Associated lymph node dissection was performed in 28 patients (homolateral: 27, bilateral: 1) and showed lymph node metastases in only two patients. One patient had distant metastases. Adjuvant irradiation was delivered to 11 patients (median: 60 Gy; range: 50-65) and chemotherapy in five cases. After a median follow-up of 5 years, six tumors relapsed, but no deaths occurred.

CONCLUSIONS

Childhood salivary gland carcinomas have a good prognosis despite possible recurrences. Treatment is mainly based on surgery, with simultaneous node dissection in cases of clinical or radiologic node enlargement. Radiation therapy seems to be restricted to inoperable high-grade tumors or after recurrence.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:140-147, 2017.

Tumors in the parotid are not relatively more often malignant in children than in adults

INTRODUCTION

Tumors of the parotid gland in children are rare and very little data has been published regarding the incidence of these tumors. We present a nationwide survey on this topic.

METHODS

Data regarding benign and malignant tumors in the parotid gland in children from January 1st, 1990 to December 31st, 2005 in Denmark was collected retrospectively from nationwide registries. This generated 61 patients for inclusion in this study.

RESULTS

85% of the tumors were benign and the malignant tumors made up the last 15%. The most common of the malignant tumors was the acinic cell carcinoma (n=4) followed by the mucoepidermoid carcinoma (n=3) and adenoid cystic carcinoma (n=2). The overall female-to-male ratio was 1.18, with a ratio of 1.08 and 2.0 in the benign and malignant groups, respectively. At the end of follow-up (August 1st, 2014) two patients had died, one with adenoid cystic carcinoma and one with mucoepidermoid carcinoma. Both patients had perineural invasion and involved resection margins at presentation. The incidence was 0.12 and 0.53 per 100,000 children of the malignant and benign tumors, respectively.

CONCLUSION

Pleomorphic adenomas were the predominant neoplasm in the parotid gland in children. The most frequent of the malignant tumors was the acinic cell carcinoma, which is in contrast to previous studies. The proportion of malignant-to-benign parotid gland tumors is in contrast to earlier study reports not higher in children than in adults.

Salivary gland carcinomas in children and adolescents: the Italian TREP project experience

BACKGROUND

Salivary gland carcinomas are extremely rare in pediatric age. We report the clinical features of a series of children/adolescents with salivary gland carcinomas prospectively registered in the Italian TREP (Rare Tumors in Pediatric Age) project.

PROCEDURES

Diagnostic/therapeutic guidelines were developed and shared among Italian pediatric oncology/surgical centers.

RESULTS

Seventeen patients were registered between 2000 and 2012, representing 19% of the cases expected to be seen based on epidemiological data. Tumors arose mainly in the parotid gland (14 cases). In most cases they were low-grade tumors (14 cases), often with a favorable clinical presentation, and low-stage disease. All patients underwent surgical resection, achieving histologically free margins in 9/17 cases. Thirteen of the 14 patients with parotid gland tumors had parotidectomy (10 total, 3 superficial), while one had a tumorectomy. Postoperative facial nerve lesions were reported in two cases. Adjuvant radiotherapy was given to 6 patients. The overall prognosis was good: only one patient with a huge high-grade tumor experienced disease progression and died of the disease. The other 16 patients were alive in first continuous remission 1-8 years after diagnosis. In 4/17 cases, the salivary gland carcinoma was a second tumor occurring 6-9 years after another primary cancer.

CONCLUSIONS

This is the first reported prospective national cooperative series of pediatric salivary gland carcinoma patients. Compliance with the TREP recommendations was high. These tumors are rarely managed by pediatric oncologists/surgeons. A broader international cooperation and better networking with otolaryngologists and head-neck surgeons expert on adult salivary gland carcinomas would be advisable.