British Journal of Radiology (2006) 79, 52-55
© 2006 British Institute of Radiology
doi: 10.1259/bjr/17905092
Lymphoepithelioma-like carcinoma of salivary glands: treatment results and failure patterns
C-Y Hsiung, MD1,
C-C Huang, MD2,
C-J Wang, MD1,
E-Y Huang, MD1 and
H-Y Huang, MD2
Departments of 1 Radiation Oncology and 2 Pathology, Chang Gung Memorial Hospital-Kaohsiung, Taiwan, R.O.C.
Correspondence: Hsuan-Ying Huang, Department of Pathology, Chang Gung Memorial Hospital-Kaohsiung, 123, Ta-Pei Road, Niao Sung Hsian, Kaohsiung Hsien, Taiwan, R.O.C
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Abstract
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The purpose of this study was to evaluate the treatment results and failure patterns of lymphoepithelioma-like carcinoma (LELC) of salivary glands. From June 1987 to May 2001, nine patients with LELC of salivary glands were treated at our hospital. One patient was excluded due to the loss of clinical follow-up after surgery. For the remaining eight patients, the primary tumour sites were parotid glands (4 patients), submandibular glands (3), and the minor salivary glands in right cheek (1), respectively. Seven patients underwent surgical treatment and post-operative radiotherapy, while the other one patient was treated with surgery only. The total radiation dose to the salivary tumour bed ranged from 39.6 Gy to 67.6 Gy (mean dose: 58.3 Gy and median dose: 59 Gy). The treatment results and failure patterns were analysed. The survival time ranged from 21.4 months to 145.2 months (mean: 69.1 months, median: 54.5 months). At the end of follow-up, six patients were still alive and two died. One patient died of distant metastases 21.5 months after the surgical treatment of LELC. The other case died of intercurrent disease (pontine haemorrhage) 53 months after surgery. No patient had local or regional failure after the treatments. Distant failure was noted in two patients. The patients with LELC of salivary glands were shown to have favourable prognoses. No local or regional failure was noted. However, distant failure developed in two patients. The risk of distant metastasis should be carefully monitored, especially for those patients with more advanced neck node involvement.
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Introduction
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Lymphoepithelioma [1] consisted of poorly differentiated cells with large nuclei and nucleoli within the lymphoid stroma. Lymphoepithelioma occurs mainly in the nasopharynx [2, 3]. Also, lymphoepithelioma-like carcinoma (LELC) has been found in salivary glands [4–6]. Because LELC is a rare histological type of cancer of salivary glands [7, 8], the clinical data concerning LELC of salivary glands is inadequate compared with other common histological types. Also, the clinical course and prognosis of this disease after the treatments have not been thoroughly studied in the medical literature. As a result, a retrospective study based on our patient database was undertaken to analyse the treatment results and failure patterns of LELC of salivary glands.
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Patients and methods
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From June 1987 to May 2001, nine patients with LELC of salivary glands were treated at our hospital. One patient was excluded due to the loss of clinical follow-up. The remaining eight patients are followed up regularly after the treatments and included in the current study. The general characteristics of these patients were shown in Table 1
. Three out of eight patients were male and five were female. The primary tumour sites were parotid glands (4 patients), submandibular glands (3), and the minor salivary glands in right cheek (1), respectively. These patients with LELC were staged according to TNM classification of the American Joint Committee on Cancer [9] (Table 1).
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Table 1. The general characteristics of the eight patients with lymphoepithelioma-like carcinoma (LELC) of salivary glands
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The treatment data of these patients are presented in Table 2. All these eight patients underwent the excision of primary salivary gland tumours. The dissection of enlarged neck lymph nodes was also performed for the five patients (patients 3, 4, 5, 6, and 8 in Table 2) with neck node metastases noted by physical examination or CT scans. After surgery, seven cases received post-operative radiotherapy with a 60Co machine or 6–10 MV linear accelerator. Six (patients 1, 3, 4, 5, 6, and 8 in Table 2) out of these seven patients were irradiated with two bilateral portals covering the salivary tumour bed and upper neck and an anterior–posterior portal covering the bilateral lower neck. The remaining one patient (patient 2 in Table 2) received small-field radiotherapy covering only salivary tumour bed without elective nodal irradiation to bilateral low neck. In the seven patients treated with post-operative radiotherapy, the total radiation dose to the salivary tumour bed ranged from 39.6 Gy to 67.6 Gy (mean dose: 58.3 Gy and median dose: 59 Gy). The dose to spinal cord was no more than 45 Gy. For the six patients receiving elective nodal irradiation to bilateral low neck, the low-neck dose ranged from 34.2 Gy to 45 Gy (Table 2).
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Table 2. The treatment data of the eight patients with lymphoepithelioma-like carcinoma (LELC) of salivary glands
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After the treatments, all the patients were followed regularly at the clinics. The treatment results and failure patterns were retrospectively reviewed. The survival time was measured from the date of the first surgical treatment to the date of last follow-up or death. The survival curves were calculated by the Kaplan-Meier product-limit method [10]. Local failure was defined as tumour recurrence in the salivary tumour bed. Regional failure was defined as tumour recurrence in the head and neck outside the salivary tumour bed.
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Results
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The histology of LELC of one patient is shown in Figure 1. The treatment results and failure patterns are summarized in Table 3. The survival time ranged from 21.4 months to 145.2 months (mean: 69.1 months, median: 54.5 months). The survival curve of these patients is shown in Figure 2. At the last follow-up, six patients were still alive and two had died. One patient died of distant metastases 21.5 months after the surgical treatment of LELC (patient 6 in Table 3). The other case died of intercurrent disease (pontine haemorrhage) 53 months after surgery (patient 1 in Table 3). No patient had local or regional failure after the treatments. However, distant metastases were noted in two patients (patients 6 and 8 in Table 3). The interval between surgery and distant failure was 6.3 months and 6.5 months for patient 6 and 8, respectively. After the occurrence of distant metastases, these two patients received chemotherapy with CDDP and 5-FU. At last follow-up, five patients were alive without cancer, one was alive with distant metastases, another one had died of distant metastases, and the remaining one had died of intercurrent disease (Table 3).
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Figure 1. The histology of lymphoepithelioma-like carcinoma (LELC) of one patient is shown here. Microscopically, diffuse lymphoid infiltration is noted around the atrophic acini of salivary gland and occasionally forms lymphoid follicles. Islands of neoplastic epithelial cells bearing pleomorphic, vesicular nuclei and indistinct cell border are present within the lymphoid tissue.
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Table 3. The treatment results and failure patterns of the eight patients with lymphoepithelioma-like carcinoma (LELC) of salivary glands
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Figure 2. The survival curve of the eight patients with lymphoepithelioma-like carcinoma (LELC) of salivary glands.
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During radiotherapy, oral mucositis and skin reaction over radiation field were experienced in all the seven patients irradiated. The major long-term complications after the treatments were xerostomia (8 patients), neck fibrosis (6 patients), and facial palsy (3 patients). The complication of facial palsy was due to tumour encasement of facial nerve and the surgical treatment.
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Discussion
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Lymphoepithelioma in nasopharynx is known as a radiosensitive tumour and radiotherapy is the standard treatment for nasopharyngeal lymphoepithelioma [2, 3]. Non-nasopharyngeal lymphoepithelioma of the head and neck is also reported to be radiosensitive with high rates of locoregional tumour control [5]. In the study of salivary gland carcinoma by Teo et al [6], seven patients had LELC from the parotid glands and only two of them experienced locoregional relapses; one had isolated regional relapse outside the post-operative radiation field 6 years after treatments and the other had in-field failure in the parotid tumour bed 3.5 years after total parotidectomy and post-operative radiation (50 Gy). In the current study, seven of these eight patients with LELC of salivary glands received surgery and post-operative radiotherapy and the other one was treated with surgery only. No local or regional failure was noted. From the results of this study and the above literature [5, 6], surgery and post-operative radiotherapy may be the appropriate treatment combination with satisfactory locoregional control for patients with LELC of salivary glands. In the future, further study with more patients is needed to find the appropriate radiation field and radiation dose for LELC of salivary glands.
Distant metastases to lung, bone, and liver were noted in two patients (patient 6 and 8, Table 3
). The duration from the date of operation to distant metastases was 6.4 months and 6.6 months for patients 6 and 8, respectively. Among these eight patients, there were four patients with N0 or N1 stage (Table 1), and none of them experienced distant metastases. The other four patients were all staged as N2b and two of them had distant metastases after the treatments. From this finding, the neck node status might be associated with the risk of distant metastases. In the study of non-nasopharyngeal lymphoepithelioma of the head and neck [5], the main cause of treatment failure was distant metastasis, which occurred more frequently in patients with lymph node involvement. As a result, the risk of distant metastasis should not be overlooked for those patients with more advanced neck node involvement.
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Conclusion
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In the current study, patients with LELC of salivary glands were shown to have favourable prognoses. No local or regional failure occurred in these patients. However, distant failure developed in two patients. The risk of distant metastasis should be carefully monitored, especially for those patients with more advanced neck node involvement.
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Acknowledgments
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The authors thank Yu-Ling Wu, M.S. for the kind assistance with manuscript preparation.
Received for publication January 5, 2005.
Accepted for publication June 7, 2005.
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References
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Abstract
Introduction
