AIIMS Retrospective evaluation

1. Dr Ajeet Kumar Gandhi
MD (AIIMS), DNB, UICCF (MSKCC,USA)
Assistant professor, Radiation oncology
Dr RMLIMS, Lucknow

2. Adenoid cystic carcinoma
 Adenoid cystic carcinoma (ACC) accounts for 1% of all head
and neck (HN) cancers and about 10-22% of all malignant
tumors of the major and minor salivary glands
 Management is challenging: local invasion, perineural
involvement, distant metastasis and recurrence over a
prolonged period
 Surgery is the cornerstone of management of ACC.
Adjuvant RT yields DFS advantage, role not well defined
 Chemotherapy use is limited to recurrent/metastatic tumors
with response rates of 10%-25%
 No consensus exists on the appropriate modality for the
management of these malignancies.

3. Materials and Methods
 Retrospective analysis of 66 patients of non-lacrimal gland ACC
of head and neck (1995-2011) treated at AIIMS, New Delhi.
 All patients evaluated in MDT
 Surgery was done primarily for all medically operable patients
 Adjuvant RT volume included tumour bed without ENI.
 Adjuvant radiation dose was 60-64 gray at 2 gray per fraction
over 6-6.5 weeks
 Concurrent cisplatin (40 mg/m2 weekly) was added in patients
with positive margin and extra-capsular extension in patients
considered eligible for this intensified approach, else a higher
dose of radiation was used in these cases

4. Results
 Ten patients had
clinical node-positive
disease
 11 necks sampled, 8
patients had
pathological node
positivity (14%)

5. Treatment Details
 57 underwent surgery, positive margin noted in 18 (31%) and PNI
in 10 (17.5%) patients.
 Adjuvant RT delivered in 54 (81.8%) patients.
 3D-CRT (25), IMRT (4) and IG-IMRT (6) patients, Rest patients 2D-
RT was used
 Median RT dose was 60 gray in 30 fractions over 6 weeks.
 Of the 18 patients with margin positive disease
 8 patients received concomitant chemotherapy (cisplatin 40
mg/m2 weekly)
 Seven patients received higher dose of radiation - 64 gray in
32 fractions over 6.5 weeks
 3 patients had re-surgical excision with negative margins

6. Clinical outcome
 Median follow-up: 23 months
(range: 12-211 months)
 Nineteen patients had a
recurrence:
 13 local
 4 distant (3 lung and 1 bone)
 2 had both local and distant
metastasis (lung metastasis)
 Two years and 4 years DFS rate
were 75% and 71%, respectively.

10. Review of literature
Study Prognostic factors
Chen et al (UCSF)
Int J Radiat Oncol Biol Phys
2006;66:152-9
T4 disease, perineural invasion,
omission of PORT, and major nerve
involvement
Gomez DR et al (MSKCC)
Int J Radiat Oncol Biol Phys 2008;
70:1365-72
T4 stage and gross
or clinical nerve involvement: PFS
T4 stage and lymph node involvement:
OS
Bjorndal et al (DAHANCA)
Oral Oncology 2015; 51:1138-42
Stage and margin status: OS & LRC on
MVA.
RT improves LRC
Takebayashi S et al
Acta Otolaryngol 2018; 138: 73-79
Multicentric retrospective analysis: RT
(>60 Gray) improves LRC and OS rate

11. Future prospects
 NOTCH1 mutations correlates with solid histology and associated
with worse outcomes
Am J Surg Pathol 2017; 41: 1473-1482
 EGFR pathway mutations and RAS mutations in SAdCC associated
with poor prognosis.
Oncotarget. 2018 Mar 30;9(24):17043-17055

12. Conclusion
 The current single institutional analysis demonstrated the
superiority of multi-modality management in the form of
surgery and adjuvant radiation in the management of HN
ACC
 Invasion of skull base/ICE and lymph node involvement
confers poor prognosis
 Stratification of patients in risk groups may help identify
those with greatest benefit from adjuvant RT
 Molecular profiling may guide treatments in times to come