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Treatment of parotid glands cancer
International Congress Series 1240 (2003) 635 – 639
Treatment of parotid glands cancer Magdalena Jozefowicz-Korczynska*, Elzbieta Debniak, Marek Lukomski Otolaryngology Department, Medical University of Lodz, 22 Kopcinskiego St., 90-153 Lodz, Poland
Abstract Parotid glands tumors are relatively uncommon but they diverse and range from less to highly aggressive. Surgery is the primary treatment of choice for most neoplasm of salivary glands. We evaluated the results of parotid gland cancer treatment dependent on clinical data and treatment modality on survival. Results of treatment, clinical stage, types of surgical management and recurrences in 105 patients with parotid gland cancer diagnosed and treated in three clinical centres were presented. The survival rate was calculated according to the Kaplan – Meier method. The patients with parotid gland cancer were treated either with surgery alone, 39 (33.9%), or with surgery and postoperative radiotherapy, 34 (29.6%). In this group, 5-year survival probability was 61%. The worst results of 5-year survival (28%) were radiotherapy alone or combined radio- and chemotherapy. Surgical treatment dominated in I and II tumor stages while in stages III and IV irradiation and chemotherapy were often performed additionally. Probability of survival depending on the operation procedure was the best for patients after subtotal parotidectomy—60%. The worst survival rate was after total parotidectomy—55% and radical total resection—50%. Fifty-one (49.5%) patients underwent a neck dissection. Postoperative complications were observed in 69 (85.2%) patients. Local – regional recurrences occurred in 21 (32.3%) of the patients. Five patients developed distance metastases. Clinical observation and statistic evaluation proved that the best treatment method was a radical surgical procedure and postoperative irradiation. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Parotid gland cancer; Therapeutic management; Surgical treatment; Complications; Survival rate
1. Introduction Salivary gland cancer represents small frequency of new cancers reported each year in about 5 – 10% of all head and neck cancer. About 25% of tumors located in the parotid * Corresponding author. Tel./fax: +48-42-6785785. E-mail address: [email protected] (M. Jozefowicz-Korczynska). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00902-6
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M. Jozefowicz-Korczynska et al. / International Congress Series 1240 (2003) 635–639
glands are malignant. The histology diversion of tumor and anatomic location of the parotid gland can make clinical decision quite different [1 –3]. Surgery has been the primary treatment for these tumors but each approach could be adapted to individual patients. Spiro et al. [4] reported local – regional recurrence after surgery alone in 39% of 623 patients with malignant parotid tumors. Armstrong et al. [5] presented the results of analysis that suggests that postoperative radiotherapy significantly improves outcome of patients with stages III and IV disease and patients with lymph node metastases. We evaluated the results of parotid gland cancer treatment dependent on clinical stage and treatment modalities.
2. Material and methods In three clinical centres ENT Clinic in Lo´dz´, ENT Clinic in Gdan´sk and Maxillo-Facial Clinic in Lo´dz´ from 1979 to 1995, 105 patients with proven parotid gland cancer were treated. There were 45 females and 60 males in the population (mean age 59.3 years). The different histologic cell types of the tumors are listed in accordance with the WHO classification. The most frequent tumor was carcinoma in pleomorphic adenoma in 18 (17.2%) patients, carcinoma planoepitheilale in 17 (16.2%) patients, then adenocarcinoma and undifferentiated carcinoma in 16 (15.3%) patients for both cases. Other tumors were rarely observed. The patients were retrospectively staged according to the criteria of the American Join Committee on Cancer. Complete follow-up of 81 patients with full documentation was performed. The survival rate was calculated according to the method of Kaplan – Meier. Procedures of the Statistical Analysis System were used for computation.
3. Results Out of 105 previously untreated patients 29, 11, 39, and 28 had stage I, II, III and IV diseases, respectively. Clinical stages were statistically significant for 5-year survival ( p = 0.014). The superficial lobe of the parotid gland was the primary tumor site in 80 (69.6%) of patients. There were 19 (16.4%) patients with T1, 32 (27.8%) patients with T2, 42 (36.5%) patients with T3 and 22 (19.1%) with T4. When the tumor size increased, the statistically significant probability of survival decreased ( p = 0.005). Palpable cervical lymph nodes had 49 (42.5%) patients in this group survival probability was statistically lower ( p = 0.0015). The choice of the treatment method depending on the clinical stage was presented in Table 1. Radiation therapy (10 patients) and chemotherapy (10 patents) were initial treatment, patients who had unrespectable primary tumor or extensive distant metastases or refused any surgical procedure. In all groups, radiotherapy was performed in 53 (50.4%) patients including 35 (33.3%) cases of conventional radiotherapy and in 18 (17.1%) cases of cobaltotherapy. Radiation therapy was successful in 44 (83.0%) patients but in 9 (17.0%) of the patients the disease was not cured. Chemotherapy was successful in nine (60.0%) patients. When the patients with parotid gland cancer were treated, only surgically or combined surgically and postoperatively irradiation, their 5-year survival probability was
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637
Table 1 Therapeutic management in different clinical stage Clinical stage
Number of patients
S
S+R
S + R + Ch
R
Ch
Untreated
I II III IV Total
29 11 37 28 105
19 5 8 7 39
7 6 14 7 34
0 0 6 4 10
2 0 5 3 10
0 0 2 8 10
0 0 2 0 2
S—surgical treatment. R—radiotherapy. Ch—chemotherapy.
61%. The worst result was after radiotherapy alone or after combined radio- and chemotherapy, 5-years survival was 28%. The effect of therapeutic management on survival in patients with parotid gland cancer is presented in Fig. 1. The surgical procedures were performed on 83 (80.6%) patients. Four types of surgical procedures such as local excision in 8 (9.6%) of patients, treated before 1975, subtotal parotidectomy in 13 (15.7%) cases, total parotidectomy with preservation of facial nerve in 21 (25.3%) patients were performed. When there was VII nerve involvement, deep lobe resection-radical total parotidectomy in 41 (49.4%) was performed. It was observed that probability of survival depending on the operation procedure was the best for patients after subtotal parotidectomy—60%. The worst survival rate was after total parotidectomy— 55% and radical total resection—50%. The effect of surgical procedure on survival in patients with parotid gland cancer is presented in Fig. 2. Fifty-one (49.5%) patients underwent a neck dissection; 18 patients had elective neck dissection, 12 selective and 21 radical neck dissection. In 10 patients, the tumor and lymph nodes were too advanced to operate; therefore, palliative treatment was performed. Postoperative complication was observed in 69 patients. The most frequent was facial
Fig. 1. The effect of therapeutic management on survival in patients with parotid gland cancer.
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M. Jozefowicz-Korczynska et al. / International Congress Series 1240 (2003) 635–639
Fig. 2. The effect of surgical procedure on survival in patients with parotid gland cancer.
nerve paresis, 30 (43.5%) complications, in 14 (20.2%) it was haematomas or necrosis and in 10 (14.5%) it was Frey syndrome. Local –regional recurrences occurred in 21 patients (32.3%) after local excision in 2 cases (40.0%), after total parotidectomy in 6 cases (35.3%) and after radical total resection in 12 cases (34.2%). Overall, 47 (58.0%) patients are currently living free of disease, while 32 patients had died of the disease before 5 years, 2 (2.5%) patients have died of other causes. The mean survival time after surgery was 12 years and 6 months. The longest observation was the case of two patients living 25 years. The mean time of symptoms was 50 months. Distance metastases were observed in five patients.
4. Discussion The treatment of parotid gland cancer is difficult because the tumor is often considered as highly aggressive, so local recurrences and metastases have been the cause of death in majority of patients. Comparing the probability of survival depending on the kind of operation, it was observed that the best prognosis was for patients after subtotal parotidectomy than other procedure. When the patients with parotid gland cancer were treated only surgically or with additional postoperative irradiation, their 5-year survival probability was much higher. Some authors, as a routine, recommend radiotherapy in aggressive gland cancer [1,2,5]. Shah and Ihide [8] and Armstrong et al. [5] suggested that radiotherapy should be used in each case of III and IV clinical stages despite lymph node status and histological type. Radiation therapy should be performed especially in undifferentiated parotid gland cancer treated operatively [6,7]. Local recurrences were observed in 33.3% of analysis cases, after local excision in 40%, seldom after superficial parotidectomy in 22% when the tumor was in I stage of advance. The 5-year survival of parotid gland carcinoma in our research was 45.8% compared with the word literature that quotes figures between 42% and 60% [5,7]. The probability of
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survival varied according to the clinical stage (70 –18%) and clinical evidence of lymph nodes (87 –14%). These survivals were rarely similar to those presented in other recent studies [7,9,10].
5. Conclusions 1. Radical surgical treatment with postoperative radiotherapy seemed to be the best treatment for patients with parotid gland cancer. 2. With increasing clinical stages and evidence of lymph nodes, the efficiency of treatment and survival rate decreased.
References [1] R. Frankenthaler, M. Luna, S. Sook Lee, A. Kie-Kian, R. Byers, O. Guillamondegui, P. Wolf, H. Goepfert, Prognostic variables in parotid gland cancer, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 1251. [2] P. Marandas, D. Dharkar, A. Leridant, L. Ojeda, C. Micheau, P. Wibault, G. Schwaab, Malignant tumours of the parotid: a study of 76 patients, Clin. Otolaryngol. 15 (2) (1990) 103. [3] J. Woods, R. Minnesota, G. Chong, Experience with 1360 primary parotid tumors, Am. J. Surg. 130 (4) (1975) 460. [4] R. Spiro, J. Armstrong, L. Harrison, N. Geller, S. Lin, E. Strong, Carcinoma of major salivary glands, Arch. Otolaryngol. Head Neck Surg. 115 (3) (1989) 316. [5] J. Armstrong, L. Harrison, R. Spiro, D. Fass, Malignant tumors of major salivary gland origin, Arch. Otolaryngol. Head Neck Surg. 116 (3) (1990) 290. [6] R. Spiro, A. Huvos, E. Strong, Cancer of the parotid gland, Am. J. Surg. 130 (5) (1975) 452 – 459. [7] M. Magnano, C.F. Gervasio, L. Cravero, G. Achetta, W. Lerda, G. Beltramo, R. Orecchia, R. Ragona, M. Bussi, Treatment of malignant neoplasm of the parotid gland, Otolaryngol. Head Neck Surg. 121 (5) (1999) 627 – 632. [8] A. Shah, J. Ihide, Salivary gland tumors, Curr. Probl. Surg. 27 (12) (1990) 775. [9] W. Kane, T. McCaffrey, P. Kerry, D. Olsen, J. Lewis, Primary parotid malignancies, Arch. Otolaryngol. Head Neck Surg. 117 (3) (1991) 307. [10] M. Poulsen, G. Pratt, B. Kynaston, Prognostic variables in malignant epithelial tumors of the parotid, Int. J. Radiat. Oncol. Biol. Phys. 23 (2) (1992) 327.
Treatment of parotid glands cancer Magdalena Jozefowicz-Korczynska*, Elzbieta Debniak, Marek Lukomski Otolaryngology Department, Medical University of Lodz, 22 Kopcinskiego St., 90-153 Lodz, Poland
Abstract Parotid glands tumors are relatively uncommon but they diverse and range from less to highly aggressive. Surgery is the primary treatment of choice for most neoplasm of salivary glands. We evaluated the results of parotid gland cancer treatment dependent on clinical data and treatment modality on survival. Results of treatment, clinical stage, types of surgical management and recurrences in 105 patients with parotid gland cancer diagnosed and treated in three clinical centres were presented. The survival rate was calculated according to the Kaplan – Meier method. The patients with parotid gland cancer were treated either with surgery alone, 39 (33.9%), or with surgery and postoperative radiotherapy, 34 (29.6%). In this group, 5-year survival probability was 61%. The worst results of 5-year survival (28%) were radiotherapy alone or combined radio- and chemotherapy. Surgical treatment dominated in I and II tumor stages while in stages III and IV irradiation and chemotherapy were often performed additionally. Probability of survival depending on the operation procedure was the best for patients after subtotal parotidectomy—60%. The worst survival rate was after total parotidectomy—55% and radical total resection—50%. Fifty-one (49.5%) patients underwent a neck dissection. Postoperative complications were observed in 69 (85.2%) patients. Local – regional recurrences occurred in 21 (32.3%) of the patients. Five patients developed distance metastases. Clinical observation and statistic evaluation proved that the best treatment method was a radical surgical procedure and postoperative irradiation. D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. Keywords: Parotid gland cancer; Therapeutic management; Surgical treatment; Complications; Survival rate
1. Introduction Salivary gland cancer represents small frequency of new cancers reported each year in about 5 – 10% of all head and neck cancer. About 25% of tumors located in the parotid * Corresponding author. Tel./fax: +48-42-6785785. E-mail address: [email protected] (M. Jozefowicz-Korczynska). 0531-5131/ D 2003 International Federation of Otorhinolaryngological Societies (IFOS). All rights reserved. doi:10.1016/S0531-5131(03)00902-6
636
M. Jozefowicz-Korczynska et al. / International Congress Series 1240 (2003) 635–639
glands are malignant. The histology diversion of tumor and anatomic location of the parotid gland can make clinical decision quite different [1 –3]. Surgery has been the primary treatment for these tumors but each approach could be adapted to individual patients. Spiro et al. [4] reported local – regional recurrence after surgery alone in 39% of 623 patients with malignant parotid tumors. Armstrong et al. [5] presented the results of analysis that suggests that postoperative radiotherapy significantly improves outcome of patients with stages III and IV disease and patients with lymph node metastases. We evaluated the results of parotid gland cancer treatment dependent on clinical stage and treatment modalities.
2. Material and methods In three clinical centres ENT Clinic in Lo´dz´, ENT Clinic in Gdan´sk and Maxillo-Facial Clinic in Lo´dz´ from 1979 to 1995, 105 patients with proven parotid gland cancer were treated. There were 45 females and 60 males in the population (mean age 59.3 years). The different histologic cell types of the tumors are listed in accordance with the WHO classification. The most frequent tumor was carcinoma in pleomorphic adenoma in 18 (17.2%) patients, carcinoma planoepitheilale in 17 (16.2%) patients, then adenocarcinoma and undifferentiated carcinoma in 16 (15.3%) patients for both cases. Other tumors were rarely observed. The patients were retrospectively staged according to the criteria of the American Join Committee on Cancer. Complete follow-up of 81 patients with full documentation was performed. The survival rate was calculated according to the method of Kaplan – Meier. Procedures of the Statistical Analysis System were used for computation.
3. Results Out of 105 previously untreated patients 29, 11, 39, and 28 had stage I, II, III and IV diseases, respectively. Clinical stages were statistically significant for 5-year survival ( p = 0.014). The superficial lobe of the parotid gland was the primary tumor site in 80 (69.6%) of patients. There were 19 (16.4%) patients with T1, 32 (27.8%) patients with T2, 42 (36.5%) patients with T3 and 22 (19.1%) with T4. When the tumor size increased, the statistically significant probability of survival decreased ( p = 0.005). Palpable cervical lymph nodes had 49 (42.5%) patients in this group survival probability was statistically lower ( p = 0.0015). The choice of the treatment method depending on the clinical stage was presented in Table 1. Radiation therapy (10 patients) and chemotherapy (10 patents) were initial treatment, patients who had unrespectable primary tumor or extensive distant metastases or refused any surgical procedure. In all groups, radiotherapy was performed in 53 (50.4%) patients including 35 (33.3%) cases of conventional radiotherapy and in 18 (17.1%) cases of cobaltotherapy. Radiation therapy was successful in 44 (83.0%) patients but in 9 (17.0%) of the patients the disease was not cured. Chemotherapy was successful in nine (60.0%) patients. When the patients with parotid gland cancer were treated, only surgically or combined surgically and postoperatively irradiation, their 5-year survival probability was
M. Jozefowicz-Korczynska et al. / International Congress Series 1240 (2003) 635–639
637
Table 1 Therapeutic management in different clinical stage Clinical stage
Number of patients
S
S+R
S + R + Ch
R
Ch
Untreated
I II III IV Total
29 11 37 28 105
19 5 8 7 39
7 6 14 7 34
0 0 6 4 10
2 0 5 3 10
0 0 2 8 10
0 0 2 0 2
S—surgical treatment. R—radiotherapy. Ch—chemotherapy.
61%. The worst result was after radiotherapy alone or after combined radio- and chemotherapy, 5-years survival was 28%. The effect of therapeutic management on survival in patients with parotid gland cancer is presented in Fig. 1. The surgical procedures were performed on 83 (80.6%) patients. Four types of surgical procedures such as local excision in 8 (9.6%) of patients, treated before 1975, subtotal parotidectomy in 13 (15.7%) cases, total parotidectomy with preservation of facial nerve in 21 (25.3%) patients were performed. When there was VII nerve involvement, deep lobe resection-radical total parotidectomy in 41 (49.4%) was performed. It was observed that probability of survival depending on the operation procedure was the best for patients after subtotal parotidectomy—60%. The worst survival rate was after total parotidectomy— 55% and radical total resection—50%. The effect of surgical procedure on survival in patients with parotid gland cancer is presented in Fig. 2. Fifty-one (49.5%) patients underwent a neck dissection; 18 patients had elective neck dissection, 12 selective and 21 radical neck dissection. In 10 patients, the tumor and lymph nodes were too advanced to operate; therefore, palliative treatment was performed. Postoperative complication was observed in 69 patients. The most frequent was facial
Fig. 1. The effect of therapeutic management on survival in patients with parotid gland cancer.
638
M. Jozefowicz-Korczynska et al. / International Congress Series 1240 (2003) 635–639
Fig. 2. The effect of surgical procedure on survival in patients with parotid gland cancer.
nerve paresis, 30 (43.5%) complications, in 14 (20.2%) it was haematomas or necrosis and in 10 (14.5%) it was Frey syndrome. Local –regional recurrences occurred in 21 patients (32.3%) after local excision in 2 cases (40.0%), after total parotidectomy in 6 cases (35.3%) and after radical total resection in 12 cases (34.2%). Overall, 47 (58.0%) patients are currently living free of disease, while 32 patients had died of the disease before 5 years, 2 (2.5%) patients have died of other causes. The mean survival time after surgery was 12 years and 6 months. The longest observation was the case of two patients living 25 years. The mean time of symptoms was 50 months. Distance metastases were observed in five patients.
4. Discussion The treatment of parotid gland cancer is difficult because the tumor is often considered as highly aggressive, so local recurrences and metastases have been the cause of death in majority of patients. Comparing the probability of survival depending on the kind of operation, it was observed that the best prognosis was for patients after subtotal parotidectomy than other procedure. When the patients with parotid gland cancer were treated only surgically or with additional postoperative irradiation, their 5-year survival probability was much higher. Some authors, as a routine, recommend radiotherapy in aggressive gland cancer [1,2,5]. Shah and Ihide [8] and Armstrong et al. [5] suggested that radiotherapy should be used in each case of III and IV clinical stages despite lymph node status and histological type. Radiation therapy should be performed especially in undifferentiated parotid gland cancer treated operatively [6,7]. Local recurrences were observed in 33.3% of analysis cases, after local excision in 40%, seldom after superficial parotidectomy in 22% when the tumor was in I stage of advance. The 5-year survival of parotid gland carcinoma in our research was 45.8% compared with the word literature that quotes figures between 42% and 60% [5,7]. The probability of
M. Jozefowicz-Korczynska et al. / International Congress Series 1240 (2003) 635–639
639
survival varied according to the clinical stage (70 –18%) and clinical evidence of lymph nodes (87 –14%). These survivals were rarely similar to those presented in other recent studies [7,9,10].
5. Conclusions 1. Radical surgical treatment with postoperative radiotherapy seemed to be the best treatment for patients with parotid gland cancer. 2. With increasing clinical stages and evidence of lymph nodes, the efficiency of treatment and survival rate decreased.
References [1] R. Frankenthaler, M. Luna, S. Sook Lee, A. Kie-Kian, R. Byers, O. Guillamondegui, P. Wolf, H. Goepfert, Prognostic variables in parotid gland cancer, Arch. Otolaryngol. Head Neck Surg. 117 (1991) 1251. [2] P. Marandas, D. Dharkar, A. Leridant, L. Ojeda, C. Micheau, P. Wibault, G. Schwaab, Malignant tumours of the parotid: a study of 76 patients, Clin. Otolaryngol. 15 (2) (1990) 103. [3] J. Woods, R. Minnesota, G. Chong, Experience with 1360 primary parotid tumors, Am. J. Surg. 130 (4) (1975) 460. [4] R. Spiro, J. Armstrong, L. Harrison, N. Geller, S. Lin, E. Strong, Carcinoma of major salivary glands, Arch. Otolaryngol. Head Neck Surg. 115 (3) (1989) 316. [5] J. Armstrong, L. Harrison, R. Spiro, D. Fass, Malignant tumors of major salivary gland origin, Arch. Otolaryngol. Head Neck Surg. 116 (3) (1990) 290. [6] R. Spiro, A. Huvos, E. Strong, Cancer of the parotid gland, Am. J. Surg. 130 (5) (1975) 452 – 459. [7] M. Magnano, C.F. Gervasio, L. Cravero, G. Achetta, W. Lerda, G. Beltramo, R. Orecchia, R. Ragona, M. Bussi, Treatment of malignant neoplasm of the parotid gland, Otolaryngol. Head Neck Surg. 121 (5) (1999) 627 – 632. [8] A. Shah, J. Ihide, Salivary gland tumors, Curr. Probl. Surg. 27 (12) (1990) 775. [9] W. Kane, T. McCaffrey, P. Kerry, D. Olsen, J. Lewis, Primary parotid malignancies, Arch. Otolaryngol. Head Neck Surg. 117 (3) (1991) 307. [10] M. Poulsen, G. Pratt, B. Kynaston, Prognostic variables in malignant epithelial tumors of the parotid, Int. J. Radiat. Oncol. Biol. Phys. 23 (2) (1992) 327.