2017 Sec 1 Green Book

C.C. Cockerill et al. / International Journal of Pediatric Otorhinolaryngology 88 (2016) 1 e 6

Fig. 1. Kaplan-Meier curve for recurrence free survival (Major gland). Total parotidectomy vs super fi cial parotidectomy vs. enucleation of tumor.

super fi cial parotidectomy ( Table 2 ; 16% vs 64% and 40% respec- tively). Based on our experience we recommend TP for deep lobe tumors, high grade, positive intraparotid lymph nodes or positive cervical lymph nodes. Enucleation of parotid tumors is strongly discouraged. Patients that present to our institution who have undergone enucleation alone at an outside facility are recom- mended to undergo completion super fi cial parotidectomy at a minimum. We recommend resection of the facial nerve only if it is grossly involved by tumor. Locoregional recurrence in our series was 28%, similar to other published series reporting 25 e 31% [10,11] . Recurrence was more likely in patients with adverse pathologic features (vascular/peri- neural invasion or extracapsular spread), who underwent enucle- ation or super fi cial parotidectomy as opposed to total parotidectomy and patients with no neck dissection ( Table 2 ). However, given the limited sample size, the only factor that reached statistical signi fi - cance was enucleation versus total parotidectomy. Recurrence occurred at a median time of 9.5 months and at a maximum time of 45 years. Therefore, we recommend at least yearly surveillance for a prolonged period in this patient population. Nodal metastasis is rare in pediatric salivary malignancies. The majority of patients who underwent neck dissection in our series had intermediate grade mucoepidermoid carcinoma and no pa- tients were found to have positive lymph nodes. In the series by Kupferman et al., only 17% of neck dissections specimens were found to harbor positive nodes [7] . The two patients in our series who developed cervical recurrences did not originally undergo neck dissection. Therefore, despite the low occurrence of cervical metastasis, we recommend neck dissection for patients with pos- itive intraparotid lymph nodes, high grade histology, clinical or radiographically suspicious lymph nodes, submandibular gland pathology and T3/T4 tumors. Neck dissection should include levels II and III for parotid tumors and level Ib for submandibular tumors unless there is clinical or radiologic evidence of suspicious lymphadenopathy outside of those regions. There is scarce literature regarding long term outcomes of pa- tients with pediatric parotid malignancies. In order to determine

6.1. Major gland

Major salivary gland tumors appear to behave substantially different than minor salivary gland tumors and therefore these fi ndings are reported separately. For major gland malignancies, we found that the majority of these tumors are low grade (66%) and present at an early stage (80%). This may explainwhy the patients in our series had an excellent prognosis with an overall disease spe- ci fi c survival of 96%. Comparatively, the adult literature reports a 47 e 65% ten year overall survival [1,8,9] . Sultan et al. reviewed the SEER database from 1974 to 2006 and likewise demonstrated that pediatric salivary gland malignancies are generally less advanced and have a better outcome than their adult counterparts [1] . Due to the good overall survival in our series we were unable to identify statistically signi fi cant factors associated with poor prognosis. However, Kupferman et al. found that age greater than 14 years, non-Caucasian ethnicity, high-grade histopathology and perineural invasion predicted for adverse survival [7] . Based on the outcomes in our series, we believe that the ma- jority of these patients can be managed with surgery alone. In fact, only 11% of patients received adjuvant radiation. Complications from radiation in our series included facial lymphedema, xero- stomia, paresthesias, external auditory canal stenosis and arrested mandibular growth requiring reconstructive surgery. Additionally, two patients developed and died from acute myeloid leukemia thought to be secondary to chemoradiation treatment received for their salivary malignancy. Risk versus bene fi t of radiation should be carefully weighed in this population given the potential for morbidity. We believe radiation therapy should be considered in patients with positive margins, high grade tumors, advanced stage, adverse pathologic factors (perineural spread, extracapsular extension, vascular invasion) and bone or soft tissue invasion. Over half (65%) of the patients with parotid tumors in our series underwent total parotidectomy (TP). The most common indications for TP in our series were deep lobe tumors or intermediate grade mucoepidermoid carcinoma. Patients who underwent TP were much less likely to recur than those who underwent enucleation or

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