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EPITHELIAL SALIVARY GLANDS MALIGNANCIES
COIMBRA’S PORTUGUESE CANCER INSTITUTE RECENT EXPERIENCE Simoes AM1, Branquinho F2, Cardoso A2, Neves A2, Cruz C2, Pereira H2, Ganho J2, Guimaraes A2
1Centro Hospitalar de Coimbra E.P.E., 2Instituto Português Oncologia Francisco Gentil (IPO FG) de Coimbra
Retrospective study with analysis of
the patients with histological
diagnosis of malignant epithelial
disease of the salivary glands
between 2000 and 2010 treated in
Coimbra’s Portuguese Cancer
Institute. Demographic information,
location, risk factors, complementary
evaluation, treatment modalities,
histological features, follow-up and
failures were analyzed.
Presented 55 cases, aged between
23 and 86 years old, 56% male. 75%
were located at the parotid, 20% in
the submandibular and 5% in minor
salivary glands. Only 2 patients
weren’t submitted to surgical
excision. Most patients were in Stage
II and IV. There were 12 (22%)
adenoid cystic carcinoma, 10 (18%)
mucoepidermoid carcinomas, 10
(18%) adenocarcinomas, 7 (13%)
acinic cell carcinoma and 16 (29%) of
several other entities. 55%
underwent radiation therapy and 18%
chemotherapy. Survival rates at 1
year were 95% and at 5 years 78%.
Failures were observed in 42% (local
and distant).
The analysis of these cases are in
line with the literature, being the
stage of the tumor the principal
prognosis factor in salivary gland
malignancies, even when dealing
with different grade histology entities.
Radiation seems to be an important
option in controlling local disease.
Ana Margarida Simoes
Centro Hospitalar Coimbra E. P. E.
Portugal, Europe
ana.simx@gmail.com
+351962574227
ABSTRACT
The pathology of the salivary glands is essentially
inflammatory and neoplastic.
Tere are multiple and complex histological subtypes with very
different byological behaviors and diagnosis difficulties
relate to the broad morphological spectrum.
Objective
Primer: to perform a comprehensive survey of the primitive
malignant diagnoses of the salivary glands and
characterized them in terms of clinical and biological
behavior.
Secondary: try to draw conclusions on the treatment and
disease control.
79 cases identified, 24 excluded, 55 evaluated.
Ages between 23 and 86 years old;
Mean age 60 yo. Age distribution as Fig. 1.
No gender preference (56% Male; 44% Female).
Time of symptoms determined in 37 cases: mean 13,2 months
with 4 of long time of evolution (14 undetermined).
Location of lesion as Fig. 2.
Associated symptoms: pain - 10 cases (18%); Facial Palsy - 8
parotid cases (20%) and cervical ganglions - 16 cases
(29%).
Exposition to risk factors such as cigarette smoke, radiation,
alcohol consumption, diabetes and immunesuppression :
rarely reported, sporadic cases of diabetes and smokers;
none with former head and neck radiation.Evaluation: ultrasound – 26 cases (47%); CT – 40 (72%);
FNAB – 45 (82%) with 33% of false negatives and 13% of
undetermined.
Histological Types as Fig. 3.
Also classified as: high grade 24 (45%), low grade 16 (30%),
intermediate 8 (15%) and undetermined 5 (10%).
Histologically there were positive ganglions in 18 cases (34%).
Clinical Stage as Fig. 4.
Retrospective Study
Basis: analysis of information contained in the clinical files of patients with salivary gland pathology treated in IPO
FG Coimbra from 2000 to 2010.
Selected those with histological diagnosis (code) of malignant neoplasm of a salivary gland.
Excluded: coding errors, very deficient information (practically nonexistent), inaccessible files.
Statistical analysis of the information – Excell data base 2007.
Used the TNM-classification of the American Joint Committe for Cancer.
All patients submitted to surgical resection, (excepted
the 2 cases staged as IVB - palliation therapy only):
from conservative sialoadenectomy to wider
excisions some with nerve repair and skin or
myocutaneous reconstruction flap.
The association with cervical lymphadenectomy
was performed in 28 patients (53%), being more or
less extended dependent on intraoperative findings,
initial stage, location, or therapeutic decision after
the initial surgery.
Adjunctive therapy with RT:
25 (45%) patients did not perform any type of
radiation.
24 (44%) underwent postoperative RT (including 2
after local recurrence) over salivary gland and / or
neck.
2 (4%) patients had local palliative RT and 7 (13%)
palliative RT for distance metastasis (cranial or
bone).
8 patients (16%) were referred for postoperative RT,
but that was not performed (exceeded optimal date
for various reasons).
The doses ranged from 50.4/28 to 68.4 Gy/38fr,
most often 59.4 Gy/33fr over the loca and neck.
10 patients (18%) had cytotoxic therapy (70%:
Carboplatin + Fluorouracil + Calcium folinate
Protocol) for distant metastasis (6), locally
advanced disease (3) and recurrence (1).
Disease recurrence: from the patients who underwent
surgery, 13 (25%) had local recurrence and 4 (6%)
also had lymph node recurrence.
Distant metastases were observed throughout the
follow-up or as early stage in 15 patients (28%).
The sites were mostly lung metastasis (11 - 73%)
and bone (60-40%) – Fig. 5.
9 patients had locally controlled disease, but
developed distant metastases
5 (56%) were in Stage IV A.
the histological types were varied without
preference for a particular entity.6 (67%) had vascular invasion on histological
examination (3 unspecified)
7 (78%) had invaded surgical margins (2 (22%) safe
margins).
7 (78%) had postoperative RT (only 1 should and did not
had (for extensive M1))
The overall median follow-up of these patients this
evaluation was 49 months.
The minimum time of survival in this series was 2 months
and a maximum of 130 months.
The Global Survival Rates were:
1 Year - 42 out of 44 (95%)
5 years - 18 out of 23 (78%)
10 years - 3 out of 8 (38%)
The survival rates were compared in the size of the lesion
(larger and smaller than 4 cm), histological grade (high,
medium and low grade) and clinical stage – results in Fig.
6a, 6b and 6c.
In this series, the most frequent lesion was adenoid cystic
carcinoma and secondary mucoepidermoid carcinoma (MEC)
– in the International literature, MEC represents 30% of all
malignant salivary gland and mimics a pleomorphic adenoma
- local pain, neurological changes and rapid growth suggest
high-grade lesion.
Internationally, there is no prevalence of gender nor obvious
tendency to occur at particular late ages; they are common in
adults, in the 5 th / 6 th decades (rare in children).
With regard to research on possible risk factors, it is our opinion
that the fact of not being actively researched, probably
conditioned the results.
Cytology as a diagnostic method can give important information,
but the results are very dependent on a meticulous
technique, that although easy it is not trivial. In this series
there was a high rate of false negatives, which may be
related to this factor.
Surgery is the treatment of choice for neoplastic salivary
pathology. Alternative therapeutic options are presented as
adjuvants.
Postoperative RT appears to reduce the risk of locoregional
recurrence and slightly increase overall survival by controlling
residual disease.
The different histological types may respond significantly
differently to chemotherapeutic agents (chemotherapy), but
there is no concrete evidence-based recommendations that
support the routine use of adjuvant chemotherapy. Therefore,
generally reserves the use of chemotherapy for palliation of
symptoms due to metastatic or locally recurrent disease, as
seen here also.
The evaluation of survival rates is only indicative due to small
sample size. We can accept that better rates are related to
low histological grade and smaller clinical stage.
In this analysis, tumor stage appears to be the most
important prognostic factor in malignant epithelial
salivary neoplasm. Radiation therapy has an
important role as adjunctive therapy. Relapse rates
are high in the long term and distant metastases
can emerge even with locally controlled disease.
1. Meyers EN, Ferris RL. Salivary Gland Disorders. Springer, 2007
2. McGurk M, Renehan A. Controversies in the management of salivary gland disease. Oxford University
Press, 2001
3. Kokemueller H, Swennen G, Brueggemann N, Brachvogel P et al. Epithelial malignancies of the
salivary glands: clinical experience of a single institution—a review. Int. J. Oral Maxillofac. Surg. 2004;
33: 423–432.
4. Jones AV, Craig GT, Speight PM, Franklin PD. The range and demographics of salivary gland tumours
diagnosed in a UK population. Oral Oncology (2008) 44, 407– 417
5. Bonito N, Broco S, Costa M, Silva R et al. Tumores adenóide císticos das glândulas salivares major –
experiência de um serviço de Oncologia. Revista Portuguesa de ORL e Cirurgia Cervico-Facial Vol 47,
Nº 3 Setembro 2009: 141-144.
CONCLUSIONS
REFERENCES
DISCUSSIONMETHODS AND MATERIALSINTRODUCTION
RESULTS
Adenoid Cystic Ca.23%
Adenocarcinoma18%
MucoepidermoidCa.18%
Acinar Cells Ca.13%
Ex-adenoma Ca.6% Undiferenciated
Ca. 6%
Salivary Duct Ca.4%
Squamous Cell Ca. 4%
Epithelial-Mioepithelial Ca.
4%
Basal Cell Adenocarcinoma
2%
Nerve Sheath Ca. 2%
Other12%
Histological Types Size <4cm >4cm
Survival Rate
1 year
29 out of 31
(94%)
13 out of 13
(100%)Survival Rate
5 years
13 out of16
(81%)
5 out of 7
(71%)Survival Rate
10 years
2 out of 6
(33%)
1 out of 2
(50%)
Grade High 24 (45%) Interm. 8 (15%) Low 16 (30%)
Survival Rate
1 year
19 out f 20
(100%)
7 out of 7
(100%)
12 out of 12
(100%)Survival Rate
5 years
4 out of 8
(50%)
4 out of 5
(80%)
8 out of 8
(100%)Survival Rate
10 years
1 out of 4
(25%)
2 out of 3
(67%)
0 out of 1
(0%)
Stage I II III IV A IV B
Survival Rate
1 year
9 out of 9
(100%)
18 out of 18
(100%)
3 out of 3
(100%)
12 out of 14
(86%)
0 out of 2
(0%)Survival Rate
5 years
2 out of 2
(100%)
10 out of 10
(100%)
2 out of 3
(67%)
4 out of 8
(50%)-
Survival Rate
10 years-
3 out of 4
(75%)
1 out of 2
(50%)
0 out of 2
(0%)-
20%
38%
7%
31%
4%
Clinical Stage
IV B IV A III II I
Figure 4.
Figure 5.
0% 50% 100%
73%40%
27%7%
Distant Metastasis
Liver Skull Bone Lung
0%
10%
20%
30%
40%
50%
0-20 21-40 41-60 61-80 81-100
09%
40%46%
5%
Years
Age DistribuitionFigure 1.
LOCATION Total ♀ ♂ Right Left
Parotid41
(75%)
17
(41%) 24 (59%)
19
(46%)
22
(54%)
Submaxilar11
(20%) 5 (45%) 6 (55%) 5 (45%) 6 (55%)
Sublingual 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Minor 3 (5%) 2 (66%) 1 (33%)
3
(100%) 0 (0%)
Figure 2.
Figure 3. Figure 6a.
Figure 6b.
Figure 6c.
RESULTS
CONTACT
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