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Adenoidcystic carcinoma in head and neck cancers

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AIIMS Retrospective evaluation

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Adenoidcystic carcinoma in head and neck cancers

  1. 1. Dr Ajeet Kumar Gandhi MD (AIIMS), DNB, UICCF (MSKCC,USA) Assistant professor, Radiation oncology Dr RMLIMS, Lucknow
  2. 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. 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. 4. Results  Ten patients had clinical node-positive disease  11 necks sampled, 8 patients had pathological node positivity (14%)
  5. 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. 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.
  7. 7. 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
  8. 8. 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
  9. 9. 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

AIIMS Retrospective evaluation

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