Performance Evaluation of Multiple Ultrasonographical Methods for the Detection of Primary Sjögren’s Syndrome

Major salivary gland ultrasonography (SGUS) is increasingly being recognized as having critical roles in differentiating primary Sjögren’s syndrome (pSS) from other connective tissue disorders. Contrast-enhanced ultrasonography (CEUS) has been reported to evaluate microvascularity of lesions in different tissues with objective angiographic index, eliminating the observer-dependent defect of ultrasonography. However, there are few relevant studies concentrating on the application of CEUS in the diagnosis and assessment for pSS, and their clinical utility prospect remains uncertain. In this study, a total of 227 eligible patients were enrolled, including 161 pSS and 66 non-pSS patients with comprehensive ultrasonographic evaluation of the parotid and submandibular glands, including grayscale ultrasonography, color Doppler sonography (CDS), and CEUS. Compared with non-pSS, pSS patients had significantly higher grayscale ultrasound (US) scores and CDS blood grades in the parotid gland and significantly higher grayscale US and CEUS scores in the submandibular glands. Diagnostic model combining ultrasonographic signatures, anti-SSA/Ro60, and keratoconjunctivitis sicca (KCS) tests showed a remarkable discrimination [mean area under the curve (AUC)0.963 in submandibular glands and 0.934 in parotid glands] for pSS, and the nomogram provided excellent prediction accuracy and good calibration in individualized prediction of pSS. A combination of multiple ultrasonographical examinations of the major salivary glands (SGs) is a promising technique that may be used as a practical alternative to minor SG biopsy in the detection of pSS.

Major Salivary Gland Cancer With Distant Metastasis Upon Presentation: Patterns, Outcomes, and Imaging Implications

Objectives Given limited data availability on distant metastasis (DM) in major salivary gland (MSG) malignancy presentation, we aimed to evaluate the rate, histologic patterns, location, and predictors of DM at first MSG cancer presentation and suggest potential implications on diagnostic workup. Study Design Retrospective cohort. Setting Commission on Cancer–accredited hospitals. Methods We included patients in the National Cancer Database (2010-2016) with MSG malignancy. Site and rate of DM were stratified by histologic subtype. Factors predictive of DM at presentation were determined by multivariate regression analysis. Survival analyses were conducted via the Kaplan-Meier method, log-rank test, and Cox regression analysis. Results Of 5776 patients with MSG carcinoma, 333 (5.8%) presented with DM. The most common DM site was the lung (57.1%), followed by bone (46.8%) and liver (19.5%). DM was most common in adenocarcinoma–not otherwise specified (15.1%, 132/874) and salivary duct carcinoma (10.4%, 30/288). High-grade mucoepidermoid carcinoma had the highest rate of lung metastases (81.6%, 31/38). Conversely, myoepithelial carcinoma had the highest rate of bone metastases (85.7%, 6/7). DM at presentation was independently associated with an increased mortality risk (hazard ratio, 1.62; 95% CI, 1.40-1.90). Conclusion We identified a DM rate of 5.8% in MSG malignancy at presentation. Overall 43% of patients presented without DM to the lung but with DM to the bones, liver, and/or brain. The most common metastatic sites differed by tumor histology. Staging with computed tomography neck and chest alone may fail to detect sites of DM; this work can be used for patient counseling in the clinical setting.

Comprehensive Treatment for Major Salivary Gland Carcinoma Based on Intensity-Modulated Radiotherapy with or without Radical Surgery

Background The present study aimed to determine a treatment strategy and Intensity-Modulated Radiotherapy (IMRT) target volume for major salivary gland carcinoma (SGC). Methods Patients with SGC treated at our cancer center between August 2009 and August 2020 were retrospectively reviewed. Results The following primary tumor sites were identified: parotid gland in 61 (69.3%) patients, submandibular gland in 21 (23.9%) patients, and sublingual gland in six (6.8%) patients. Lymphoepithelial carcinoma (LEC) was the most common tumor subtype that accounted for 23.9% of cases. A total of 80 (90.9%) patients received radical surgery combined with postoperative radiotherapy. Eight patients (9.1%) received definitive radiotherapy: six patients with advanced-stage disease received induction chemotherapy (IC) combined with concurrent chemoradiotherapy (CCRT), and two patients with early-stage disease received CCRT. Complete response was observed in these eight patients after treatment completion. The median follow-up time of all patients was 42 months (range: 4–129 months). No patient developed local recurrence. The 5-year overall survival, regional failure-free survival, distant metastasis-free survival, and progression-free survival probabilities were 84.1%, 95.6%, 75.3%, and 75.7%, respectively. Distant metastasis was observed in 18 (20.5%) patients, followed by regional 2 (2.3%) recurrence. Permanent facial nerve injury was confirmed in 31 patients by follow-up. None of the patients experienced facial nerve paralysis in the definitive radiotherapy group. Conclusions LECs may be sensitive to chemoradiotherapy, which may achieve a radical effect and avoid unnecessary surgical injury. IC combined with CCRT is expected to become a new treatment strategy for advanced LECs. The IMRT target volume delineation according to the surgical principles may be a more promising method with good clinical efficacy that is worthy of further study.

1196 Sonographic Assessment Versus Direct Clinical Measurement of Sialolith Size and Its Influence on Modality of Endoscopic Removal

Aim The aim of this retrospective case series was to investigate the influence of sialolith size on the potential for endoscopic stone removal. Method The records of 52 patients who underwent salivary endoscopy between September 2018 and February 2020 were reviewed. Included cases presented with at least one symptomatic major salivary gland, and sonographic or radiographic evidence of stone disease. Results A total of 25 patients (48%) and 27 stones were identified. These patients had a mean age of 45.2 years (range 16–72); 52% were female. Most cases (19/25) involved the submandibular gland, with a virtually even division between left and right sides. The overall success rate of sialendoscopic retrieval was 23/27 (85%), with 17/27 stones removed intact and 6/27 undergoing fragmentation with an intraoral salivary pneumatic lithotripter (Cook Medical). Median (sonographic) stone size in the largest dimension for those stones removed intact was 4mm (range 3-12mm), while for those undergoing fragmentation it was 7mm (range 3-11mm). Ultrasound provided an accurate assessment of stone size in most cases, but underestimated diameter by an average of 1mm in 6/27 cases, and overestimated size by 1mm in a single case. Conclusions Sialendoscopic stone retrieval is a minimally invasive and effective treatment for sialolithiasis. It is possible to remove most stones using a basket, with intraoral lithotripsy employed for larger stones. Ultrasound is a reliable diagnostic tool for predicting stone size but may underestimate size in a small proportion of cases.

1203 Sialendoscopy In Non-Stone Sialadenitis Is an Effective Therapeutic Approach

Introduction The aim of this retrospective case series was to investigate the therapeutic effectiveness of salivary endoscopy for non-stone related sialadenitis and obstructive symptoms. Method The records of 46 patients who underwent salivary endoscopy between September 2018 and December 2019 were reviewed. Included cases presented with at least one symptomatic major salivary gland, with no history or evidence of stone disease on clinical or radiologic examinations. Results A total of 22 patients (48%) and 26 glands were identified. These patients had a mean age of 50.8 years (range 27–74) and 73% were female. Most cases (19/26) involved the parotid gland. The primary imaging modality used was ultrasound, with sialography reserved for suspected strictures. The most common sonographic finding was ductal dilation (50%). Dexamethasone was instilled at completion of sialendoscopy in 23/26 cases. Outcomes included symptomatic improvement in 15/18 patients (4 patients have follow-up pending) with 5/15 experiencing complete symptom resolution. 2/18 patients did not have any symptomatic improvement, and 1/18 experienced acute infection that was treated with antibiotics. No patients required gland excision. Conclusions Salivary endoscopy is a minimally invasive and effective treatment for patients with non-stone sialadenitis that is refractory to conservative measures. Our review demonstrated 83% therapeutic benefit with gland preservation in all patients.

1341 Outcomes of Sialendoscopic Stone Retrieval Under Local Anaesthesia in The Outpatient Setting- A Single Surgeon’s Experience

Aim The aim of this retrospective case series was to investigate the success rate of sialendoscopic stone retrieval under local anaesthetic. Method The records of 52 patients who underwent salivary endoscopy between September 2018 and February 2020 were reviewed. Included cases presented with at least one symptomatic major salivary gland, and sonographic or radiographic evidence of stone disease. Results A total of 25 patients (48%) and 27 stones were identified. Most cases (19/25) involved the submandibular gland, with a virtually even division between left and right sides. 19/25 patients underwent stone retrieval under local anaesthetic (LA) in the first instance (two of these patients had two stones). 6/25 patients underwent stone retrieval under general anaesthetic (GA) in the first instance, and this was successful in 5/6 cases. The overall success rate of LA sialendoscopic stone retrieval was 18/21 (86%), with 14/21 stones (66%) being successfully removed at the first treatment session and a further four at the subsequent treatment session. Under LA, 13/18 stones were removed intact, while the remaining 5 underwent fragmentation with an intraoral salivary pneumatic lithotripter (Cook Medical). Conclusions Sialendoscopic stone retrieval is a minimally invasive and effective treatment for both submandibular and parotid duct stones. It is possible to remove most stones under local anaesthetic at the first treatment session, using intraoral lithotripsy as an adjunct when indicated. This treatment modality provides therapeutic benefit with 86% success of stone retrieval under local anaesthetic with gland preservation in the vast majority of patients.

Polymorphous adenocarcinoma of the submandibular gland

Polymorphous adenocarcinoma (PA) of the salivary glands is a rare malignancy that predominantly affects the minor salivary glands of the palate. Major salivary gland involvement is rare (<5%). The submandibular gland is a highly unusual location for this tumour. Recently, the WHO has updated the classification of salivary gland tumours in which the PA subtype has been modified. We report a very uncommon case of a classical variant of PA involving the submandibular gland in a 49-year-old woman managed at our institute and discuss the most recent pathological criteria for diagnosis, management strategy and prognosis of PA.

Proton Therapy for Major Salivary Gland Cancer: Clinical Outcomes

Purpose To report clinical outcomes in terms of disease control and toxicity in patients with major salivary gland cancers (SGCs) treated with proton beam therapy. Materials and Methods Clinical and dosimetric characteristics of patients with SGCs treated from August 2011 to February 2020 on an observational, prospective, single-institution protocol were abstracted. Local control and overall survival were calculated by the Kaplan-Meier method. During radiation, weekly assessments of toxicity were obtained, and for patients with ≥ 90 days of follow-up, late toxicity was assessed. Results Seventy-two patients were identified. Median age was 54 years (range, 23-87 years). Sixty-three patients (88%) received postoperative therapy, and nine patients (12%) were treated definitively. Twenty-six patients (36%) received concurrent chemotherapy. Nine patients (12%) had received prior radiation. All (99%) but one patient received unilateral treatment with a median dose of 64 GyRBE (relative biological effectiveness) (interquartile range [IQR], 60-66), and 53 patients (74%) received intensity-modulated proton therapy with either single-field or multifield optimization. The median follow-up time was 30 months. Two-year local control and overall survival rates were 96% (95% confidence interval [CI] 85%-99%) and 89% (95% CI 76%-95%], respectively. Radiation dermatitis was the predominant grade-3 toxicity (seen in 21% [n = 15] of the patients), and grade ≥ 2 mucositis was rare (14%; n = 10 patients). No late-grade ≥ 3 toxicities were reported. Conclusion Proton beam therapy for treatment of major SGCs manifests in low rates of acute mucosal toxicity. In addition, the current data suggest a high rate of local control and minimal late toxicity.