ORIGINAL ARTICLE
International collaborative validation of intraneural invasion as a prognostic marker in adenoid cystic carcinoma of the head and neck Moran Amit, MD, MSc,1 Yoav Binenbaum, MD,1 Leonor Trejo–Leider, MD,2 Kanika Sharma, MD,3 Naomi Ramer, DMD,4 Ilana Ramer, MD,4 Abib Agbetoba, MD,5 Brett Miles, DDS, MD,5 Xinjie Yang, MD, PhD,6 Delin Lei, MD,6 Kristine Bjïrndal, MD, PhD,7 Christian Godballe, MD, PhD,7 Thomas M€ucke, MD, DDS, PhD,8 Klaus-Dietrich Wolff, MD, DDS, PhD,8 Andre M. Eckardt, MD, DDS, PhD,9 Chiara Copelli, MD,10 Enrico Sesenna, MD,10 Frank Palmer,11 Ian Ganly, MD,11 Snehal Patel, MD,11 Ziv Gil, MD, PhD1,12* 1
The Laboratory for Applied Cancer Research, the Clinical Research Center at Rambam, Rambam Medical Center, Rappaport Medical School, The Technion, Israel Institute of Technology, Haifa, Israel, 2Department of Pathology, Tel Aviv Medical Center, Tel Aviv, Israel, 3Department of Radiotherapy and Oncology, Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi, India, 4Department of Pathology, The Mount Sinai School of Medicine, New York, New York, 5Department of Otolaryngology, Ichan School of Medicine at Mount Sinai, New York, New York, 6Department of Oral and Maxillofacial Surgery, School of Stomatology, the Fourth Military Medical University, People’s Republic of China, 7 Department of Otolaryngology Head and Neck Surgery, Odense University Hospital Odense, Denmark, 8Department of Oral and Maxillofacial Surgery, Technische Universit€at M€unchen, M€unchen, Germany, 9Department of Cranio-Maxillofacial Surgery, Hannover Medical School, Hannover, Germany, 10Maxillo-Facial Surgery, University-Hospital of Parma, Italy, 11Head and Neck Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York, 12Department of Otolaryngology Head and Neck Surgery, Department of Otolaryngology Head and Neck Surgery, Rambam Medical Center, The Technion, Israel Institute of Technology, Haifa, Israel.
Accepted 4 April 2014 Published online 24 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23710
ABSTRACT: Background. The purpose of this study was to characterize the incidence, pattern of spread, and prognostic correlation of nerve invasion in patients with adenoid cystic carcinoma (ACC). Methods. Using 3 different pathological categories of perineural invasion, intraneural invasion, and perineural inflammation, we investigated the prognostic value of nerve invasion in a total of 495 ACCs from 9 international patient cohorts with median follow-up 90 months (range, 12–288 months). Results. Of 239 patients (48%) with nerve invasion, 174 (73%) had perineural invasion, 65 (27%) intraneural invasion, and 37 (15%) perineural inflammation. Multivariate Cox regression analysis identified tumor site (p 5 .008; hazard ratio [HR] 5 1.8; 95% confidence interval
INTRODUCTION Adenoid cystic carcinoma (ACC) is the second most common malignant salivary gland tumor in the head and neck.1,2 The natural history of ACC is characterized by an intermediate growth rate, a high rate of local recurrence, and frequent finding of distant metastases.1,2 Most of the ACCs are considered as being resistant to radiation therapy and therefore the mainstay of treatment is surgery. The hallmark of ACC is its high propensity to invade nerves.3 The tendency of tumors to invade nerves was traditionally termed “perineural invasion” because of
*Corresponding author: Z. Gil, Department of Otolaryngology Rambam Medical Center, Rappaport School of Medicine, The Technion, Israel Institute of Technology, Haifa, Israel. E-mail: [email protected] Contract grant sponsor: This research was supported by the Weizmann Institute – TASMC Joint Grant, the ICRF Barbara S. Goodman endowed research career development award (2011-601-BGPC), and a grant from the US-Israel Binational Science Foundation. . Additional Supporting Information may be found in the online version of this article.
1038
HEAD & NECK—DOI 10.1002/HED
JULY 2015
[CI] 5 0.07–3.7) and intraneural invasion (p < .001; HR 5 5.9; 95% CI 5 0.8–12.3) as independent prognostic markers for both overall survival (OS) and disease-specific survival (DSS), but not of distant metastases. Conclusion. Although perineural invasion has no impact on survival, intraneural invasion is an independent predictor of poor prognosis. Recognition of intraneural invasion may help optimize treatment of patients C 2014 Wiley Periodicals, Inc. Head Neck 37: with head and neck ACC. V 1038–1045, 2015
KEY WORDS: adenoid cystic carcinoma, survival, perineural invasion, intraneural invasion, salivary gland, head and neck cancer
the invasion of cancer cells through the perineural sheath. In the majority of cases, perineural invasion is not associated with neurological symptoms or cranial nerve palsy, however, local or referred pain is a warning sign of malignancy in salivary gland tumors. In several other cancers, including those of the prostate and pancreas, nerve invasion is associated with significant morbidity and poor outcome, but it has not been determined whether it is associated with survival or local recurrence in patients with ACC.4,5 The traditional classification of tumors with nerve invasion is based on the involvement of a named or unnamed nerve.6 An alternative classification is based on the nerves’ diameter.3 Histopathological features of nerve invasion include perineural invasion defined as the presence of viable tumor cells in the perineural space, intraneural invasion defined as the presence of perineural invasion with tumor cells invading into and/or with irregular destruction of the axon of the nerve bundles, as reported previously, and the presence of perineural inflammation (invasion of cancer cells into the perineural space with the presence of lymphocytic infiltration).7,8
NEURAL
INVASION IN ADENOID CYSTIC CARCINOMA
TABLE 1. Patient demographics. Variables
Mean age, y Sex Male Female Treatment Surgery Surgery 1 radiotherapy Surgery 1 chemoradiotherapy Type of neck dissection Elective Therapeutic Extent of neck dissection I I–III I–IV/V Bilateral Site Major salivary glands Minor salivary gland, oral cavity Minor salivary gland, sinonasal Larynx T classification 1 2 3 4 N classification N0 N1 N2 M classification M0 M1 Overall TNM classification I II III IV Neural invasion features Named nerve Perineural invasion Intraneural invasion Perineural inflammation Follow-up all patients, months Mean Median Range
Patients without neural invasion, n 5 256 (%)
Patients with neural invasion, n 5 239 (%)
p value
56 6 15.5
56 6 14.7
.8
106 (41) 150 (59)
104 (44) 135 (56)
.96
120 (47) 99 (39) 37 (14)
72 (30) 126 (53) 41 (17)
.93
100 (39) 44 (17)
93 (39) 35 (15)
.92
5 (2) 106 (41) 21 (8) 12 (5)
11 (5) 79 (33) 22 (9) 16 (7)
.89
77 (30) 129 (50) 48 (19) 2 (1)
65 (27) 121 (51) 51 (21) 2 (1)
.94
73 (29) 96 (37) 25 (10) 62 (24)
41 (17) 77 (32) 45 (19) 76 (32)
.54
219 (85) 17 (7) 20 (8)
198 (83) 23 (10) 18 (7)
.91
246 (96) 10 (4)
223 (94) 14 (6)
.93
62 (24) 81 (32) 33 (13) 80 (31)
43 (18) 65 (27) 39 (16) 92 (39)
.67
102 (43) 174 (73) 65 (27) 37 (15)
N/A 102 6 45 96 12–256
88 6 55 82 12–288
.77
Abbreviation: N/A, not applicable.
Although perineural invasion is considered by most authors not to be associated with outcome, the impact of intraneural invasion on prognosis of patients with ACC has never been addressed. In order to overcome limitations of previous studies on ACC, which arise from small cohorts of patients and short follow-up periods, we retrieved detailed histopathological and clinical data from 9 cancer centers worldwide. This multicenter study of ACC was aimed to reveal the clinical implication of nerve invasion on outcome and identify risk factors for the poor prognosis in this population, including perineural
invasion and inflammation, intraneural invasion, and named nerve invasion.
PATIENTS AND METHODS Patients Our study cohort included all patients (n 5 495) who were treated for ACC between 1985 and 2011 in 9 cancer centers worldwide with available data and archival slides for examination. The study was approved by the local institutional review board committees of the participating HEAD & NECK—DOI 10.1002/HED
JULY 2015
1039
AMIT ET AL.
FIGURE 1. (A) Adenoid cystic carcinoma (ACC) with perineural invasion and (B) intraneural invasion with infiltration of cancer cells between the nerve fascicles. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
centers. The age of the patients ranged from 16 to 91 years (median, 56 years). Their median follow-up was 90 months (range, 12–288 months). Table 1 presents the demographic and clinical data of the study participants. They had all undergone primary surgery, with or without adjuvant radiotherapy or chemoradiation. A standardized neck dissection involving levels I, I to III, or I to IV/V was performed in 272 patients (55%), as described by the American Head and Neck Society.9 The type of neck dissection was preoperatively specified in all patients.
Histopathological analysis Specimen dissections as well as tissue sampling of the primary tumor were carried out according to current guidelines for the histopathological assessment of head and neck cancer carcinoma.10 According to nerve invasion severity, we differentiated between 2 nerve invasion stages: first, perineural invasion (Figure 1A): defined as tumor cells found within the perineural space. Second, the infiltration of cancer cells into the endoneurium, where they are completely encountered within the nerve fascicles: intraneural invasion (Figure 1B). Consecutive 3-mm paraffin-embedded tissue sections of ACC were analyzed for perineural invasion and other pathologic parameters were carried out by 1 institutional head and neck pathologist. Questionable cases were reexamined by 2 pathologists. On average, 16 tissue sections (median, 21; range, 5–62) were analyzed for the presence and severity of nerve invasion in each patient making the total sum of approximately 7900 analyzed sections. The cases were examined for the presence or absence of perineural invasion, which was defined as the presence of viable tumor cells in the perineural space. The presence of acellular material in the perineural space with no viable tumor cells was considered as negative for perineural invasion in this study. The presence of intraneural invasion was defined by histology as the presence of perineural invasion with tumor cells invading into and/or with irregular destruction of the axon of the nerve bundles, as reported previously.7 The maximum diameter of the nerves 1040
HEAD & NECK—DOI 10.1002/HED
JULY 2015
involved by tumor was measured microscopically. The involvement of a named nerve was determined based on the anatomic location and nerve size. If any of the resection margins was involved by ACC, the case was classified as margin positive, if the resection margins were not involved, yet 45 45* Pathologic T classification T1* T2 T3 T4 Pathologic N classification N0* N1 Distant metastasis M0* M1 Site Major* Oral cavity Sinonasal Larynx Treatment Surgery* Surgery 1 RT Surgery 1 CRT Tumor grade Solid Cribriform Tubular* Named nerve Yes No* Nerve size, mm Margin status Negative* Positive Close Perineural invasion Intraneural invasion Perineural inflammation
DSS
Univariate p value
Multivariate p value
HR (95% CI)
.01
.93
5.2 (0.3–13.2)
.001
.05
International collaborative validation of intraneural invasion as a prognostic marker in adenoid cystic carcinoma of the head and neck Moran Amit, MD, MSc,1 Yoav Binenbaum, MD,1 Leonor Trejo–Leider, MD,2 Kanika Sharma, MD,3 Naomi Ramer, DMD,4 Ilana Ramer, MD,4 Abib Agbetoba, MD,5 Brett Miles, DDS, MD,5 Xinjie Yang, MD, PhD,6 Delin Lei, MD,6 Kristine Bjïrndal, MD, PhD,7 Christian Godballe, MD, PhD,7 Thomas M€ucke, MD, DDS, PhD,8 Klaus-Dietrich Wolff, MD, DDS, PhD,8 Andre M. Eckardt, MD, DDS, PhD,9 Chiara Copelli, MD,10 Enrico Sesenna, MD,10 Frank Palmer,11 Ian Ganly, MD,11 Snehal Patel, MD,11 Ziv Gil, MD, PhD1,12* 1
The Laboratory for Applied Cancer Research, the Clinical Research Center at Rambam, Rambam Medical Center, Rappaport Medical School, The Technion, Israel Institute of Technology, Haifa, Israel, 2Department of Pathology, Tel Aviv Medical Center, Tel Aviv, Israel, 3Department of Radiotherapy and Oncology, Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi, India, 4Department of Pathology, The Mount Sinai School of Medicine, New York, New York, 5Department of Otolaryngology, Ichan School of Medicine at Mount Sinai, New York, New York, 6Department of Oral and Maxillofacial Surgery, School of Stomatology, the Fourth Military Medical University, People’s Republic of China, 7 Department of Otolaryngology Head and Neck Surgery, Odense University Hospital Odense, Denmark, 8Department of Oral and Maxillofacial Surgery, Technische Universit€at M€unchen, M€unchen, Germany, 9Department of Cranio-Maxillofacial Surgery, Hannover Medical School, Hannover, Germany, 10Maxillo-Facial Surgery, University-Hospital of Parma, Italy, 11Head and Neck Surgery Service, Memorial Sloan Kettering Cancer Center, New York, New York, 12Department of Otolaryngology Head and Neck Surgery, Department of Otolaryngology Head and Neck Surgery, Rambam Medical Center, The Technion, Israel Institute of Technology, Haifa, Israel.
Accepted 4 April 2014 Published online 24 July 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23710
ABSTRACT: Background. The purpose of this study was to characterize the incidence, pattern of spread, and prognostic correlation of nerve invasion in patients with adenoid cystic carcinoma (ACC). Methods. Using 3 different pathological categories of perineural invasion, intraneural invasion, and perineural inflammation, we investigated the prognostic value of nerve invasion in a total of 495 ACCs from 9 international patient cohorts with median follow-up 90 months (range, 12–288 months). Results. Of 239 patients (48%) with nerve invasion, 174 (73%) had perineural invasion, 65 (27%) intraneural invasion, and 37 (15%) perineural inflammation. Multivariate Cox regression analysis identified tumor site (p 5 .008; hazard ratio [HR] 5 1.8; 95% confidence interval
INTRODUCTION Adenoid cystic carcinoma (ACC) is the second most common malignant salivary gland tumor in the head and neck.1,2 The natural history of ACC is characterized by an intermediate growth rate, a high rate of local recurrence, and frequent finding of distant metastases.1,2 Most of the ACCs are considered as being resistant to radiation therapy and therefore the mainstay of treatment is surgery. The hallmark of ACC is its high propensity to invade nerves.3 The tendency of tumors to invade nerves was traditionally termed “perineural invasion” because of
*Corresponding author: Z. Gil, Department of Otolaryngology Rambam Medical Center, Rappaport School of Medicine, The Technion, Israel Institute of Technology, Haifa, Israel. E-mail: [email protected] Contract grant sponsor: This research was supported by the Weizmann Institute – TASMC Joint Grant, the ICRF Barbara S. Goodman endowed research career development award (2011-601-BGPC), and a grant from the US-Israel Binational Science Foundation. . Additional Supporting Information may be found in the online version of this article.
1038
HEAD & NECK—DOI 10.1002/HED
JULY 2015
[CI] 5 0.07–3.7) and intraneural invasion (p < .001; HR 5 5.9; 95% CI 5 0.8–12.3) as independent prognostic markers for both overall survival (OS) and disease-specific survival (DSS), but not of distant metastases. Conclusion. Although perineural invasion has no impact on survival, intraneural invasion is an independent predictor of poor prognosis. Recognition of intraneural invasion may help optimize treatment of patients C 2014 Wiley Periodicals, Inc. Head Neck 37: with head and neck ACC. V 1038–1045, 2015
KEY WORDS: adenoid cystic carcinoma, survival, perineural invasion, intraneural invasion, salivary gland, head and neck cancer
the invasion of cancer cells through the perineural sheath. In the majority of cases, perineural invasion is not associated with neurological symptoms or cranial nerve palsy, however, local or referred pain is a warning sign of malignancy in salivary gland tumors. In several other cancers, including those of the prostate and pancreas, nerve invasion is associated with significant morbidity and poor outcome, but it has not been determined whether it is associated with survival or local recurrence in patients with ACC.4,5 The traditional classification of tumors with nerve invasion is based on the involvement of a named or unnamed nerve.6 An alternative classification is based on the nerves’ diameter.3 Histopathological features of nerve invasion include perineural invasion defined as the presence of viable tumor cells in the perineural space, intraneural invasion defined as the presence of perineural invasion with tumor cells invading into and/or with irregular destruction of the axon of the nerve bundles, as reported previously, and the presence of perineural inflammation (invasion of cancer cells into the perineural space with the presence of lymphocytic infiltration).7,8
NEURAL
INVASION IN ADENOID CYSTIC CARCINOMA
TABLE 1. Patient demographics. Variables
Mean age, y Sex Male Female Treatment Surgery Surgery 1 radiotherapy Surgery 1 chemoradiotherapy Type of neck dissection Elective Therapeutic Extent of neck dissection I I–III I–IV/V Bilateral Site Major salivary glands Minor salivary gland, oral cavity Minor salivary gland, sinonasal Larynx T classification 1 2 3 4 N classification N0 N1 N2 M classification M0 M1 Overall TNM classification I II III IV Neural invasion features Named nerve Perineural invasion Intraneural invasion Perineural inflammation Follow-up all patients, months Mean Median Range
Patients without neural invasion, n 5 256 (%)
Patients with neural invasion, n 5 239 (%)
p value
56 6 15.5
56 6 14.7
.8
106 (41) 150 (59)
104 (44) 135 (56)
.96
120 (47) 99 (39) 37 (14)
72 (30) 126 (53) 41 (17)
.93
100 (39) 44 (17)
93 (39) 35 (15)
.92
5 (2) 106 (41) 21 (8) 12 (5)
11 (5) 79 (33) 22 (9) 16 (7)
.89
77 (30) 129 (50) 48 (19) 2 (1)
65 (27) 121 (51) 51 (21) 2 (1)
.94
73 (29) 96 (37) 25 (10) 62 (24)
41 (17) 77 (32) 45 (19) 76 (32)
.54
219 (85) 17 (7) 20 (8)
198 (83) 23 (10) 18 (7)
.91
246 (96) 10 (4)
223 (94) 14 (6)
.93
62 (24) 81 (32) 33 (13) 80 (31)
43 (18) 65 (27) 39 (16) 92 (39)
.67
102 (43) 174 (73) 65 (27) 37 (15)
N/A 102 6 45 96 12–256
88 6 55 82 12–288
.77
Abbreviation: N/A, not applicable.
Although perineural invasion is considered by most authors not to be associated with outcome, the impact of intraneural invasion on prognosis of patients with ACC has never been addressed. In order to overcome limitations of previous studies on ACC, which arise from small cohorts of patients and short follow-up periods, we retrieved detailed histopathological and clinical data from 9 cancer centers worldwide. This multicenter study of ACC was aimed to reveal the clinical implication of nerve invasion on outcome and identify risk factors for the poor prognosis in this population, including perineural
invasion and inflammation, intraneural invasion, and named nerve invasion.
PATIENTS AND METHODS Patients Our study cohort included all patients (n 5 495) who were treated for ACC between 1985 and 2011 in 9 cancer centers worldwide with available data and archival slides for examination. The study was approved by the local institutional review board committees of the participating HEAD & NECK—DOI 10.1002/HED
JULY 2015
1039
AMIT ET AL.
FIGURE 1. (A) Adenoid cystic carcinoma (ACC) with perineural invasion and (B) intraneural invasion with infiltration of cancer cells between the nerve fascicles. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.]
centers. The age of the patients ranged from 16 to 91 years (median, 56 years). Their median follow-up was 90 months (range, 12–288 months). Table 1 presents the demographic and clinical data of the study participants. They had all undergone primary surgery, with or without adjuvant radiotherapy or chemoradiation. A standardized neck dissection involving levels I, I to III, or I to IV/V was performed in 272 patients (55%), as described by the American Head and Neck Society.9 The type of neck dissection was preoperatively specified in all patients.
Histopathological analysis Specimen dissections as well as tissue sampling of the primary tumor were carried out according to current guidelines for the histopathological assessment of head and neck cancer carcinoma.10 According to nerve invasion severity, we differentiated between 2 nerve invasion stages: first, perineural invasion (Figure 1A): defined as tumor cells found within the perineural space. Second, the infiltration of cancer cells into the endoneurium, where they are completely encountered within the nerve fascicles: intraneural invasion (Figure 1B). Consecutive 3-mm paraffin-embedded tissue sections of ACC were analyzed for perineural invasion and other pathologic parameters were carried out by 1 institutional head and neck pathologist. Questionable cases were reexamined by 2 pathologists. On average, 16 tissue sections (median, 21; range, 5–62) were analyzed for the presence and severity of nerve invasion in each patient making the total sum of approximately 7900 analyzed sections. The cases were examined for the presence or absence of perineural invasion, which was defined as the presence of viable tumor cells in the perineural space. The presence of acellular material in the perineural space with no viable tumor cells was considered as negative for perineural invasion in this study. The presence of intraneural invasion was defined by histology as the presence of perineural invasion with tumor cells invading into and/or with irregular destruction of the axon of the nerve bundles, as reported previously.7 The maximum diameter of the nerves 1040
HEAD & NECK—DOI 10.1002/HED
JULY 2015
involved by tumor was measured microscopically. The involvement of a named nerve was determined based on the anatomic location and nerve size. If any of the resection margins was involved by ACC, the case was classified as margin positive, if the resection margins were not involved, yet 45 45* Pathologic T classification T1* T2 T3 T4 Pathologic N classification N0* N1 Distant metastasis M0* M1 Site Major* Oral cavity Sinonasal Larynx Treatment Surgery* Surgery 1 RT Surgery 1 CRT Tumor grade Solid Cribriform Tubular* Named nerve Yes No* Nerve size, mm Margin status Negative* Positive Close Perineural invasion Intraneural invasion Perineural inflammation
DSS
Univariate p value
Multivariate p value
HR (95% CI)
.01
.93
5.2 (0.3–13.2)
.001
.05
