Prognosis and predictive factors

The average among several studies is a recurrence rate of about 35% and a metastatic rate and disease-associated death incidence of about 16% {441,478, 670,960,994,1060,1 1 12,1492,1845, 1938,2017,2515,2607}. Multiple recurrences and metastasis to cervical lymph nodes indicate a poor prognosis. Distant metastasis is associated with very poor survival. While tumours in the sub-mandibular gland are more aggressive than those in the parotid gland, acinic cell carcinomas in minor salivary glands are less aggressive than those in the major salivary glands {340,864,1112, 2886}.

Attempts at histological grading have been controversial and inconsistent. Features that are often associated with more aggressive tumours include frequent mitoses, focal necrosis, neural invasion, pleomorphism, infiltration, and stromal hyalinisation {161,650,670,960, 2017,2445}. Occasional cases of dedifferentiation from a low-grade to a highgrade malignancy have been reported. These tumours are characterized by cytological pleomorphism, increased mitotic and proliferation indices and have a worse prognosis {594,1063,1911, 2459}.

Staging is often a better predictor of outcome than histomorphologic grading. Large size, involvement of the deep lobe of the parotid gland, and incomplete resection indicate a poor prognosis. The cell proliferation marker Ki-67 has shown the most promise as a predictor of biological behaviour. No recurrences of acinic cell carcinomas were seen when the percentage of positively immunos-tained tumour cells was below 5% whereas most patients with tumour indices above 10% had unfavourable outcomes {1060,2388}.

Fig. 5.4 Acinic cell carcinoma. High-grade, poorly differentiated carcinoma (right) and typical acinic cell carcinoma (left) in a single neoplasm has been designated as "dedifferentiated" acinic cell carcinoma.

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