The Journal of Laryngology and Otology April 1979. Vol. 93. pp. 423-426
Acinic cell carcinoma of intraoral minor salivary gland origin By D. C. FERMONT (London)
Introduction cell carcinoma is a well-described histological entity found in salivary gland neoplasms. There have been a number of published series which have included examples of this disease affecting the major salivary glands. However, its occurrence in minor salivary gland tissue appears to be rare. An analysis of 1,414 cases of minor salivary intraoral gland tumours by Chaudhry et al. (1961), over a thirty-three-year period (1927-1960) yielded a solitary case. There appears to have been one previous detailed case report by Baden and Wallen (1965). ACINIC
Case report A 64-year-old male was referred to the E.N.T. department at his local hospital by his general practitioner. He gave a four-month history of hoarseness of voice which had become worse during the preceeding 3 weeks. He also complained of dysphagia for solids, discomfort in the left ear and an episode of haemoptysis. Examination revealed a well-nourished individual with a thick voice. Inspection of the oral cavity showed him to be edentulous. Depression of the tongue with a spatula revealed a large tumour situated posteriorly on the left side. There was no cervical lymphadenopathy. The patient was admitted for investigation and biopsy. General physical examination was unremarkable. There was no evidence of anaemia and an E.S.R. of 15 mm/hr (Westergren) was recorded. A P.A. chest x-ray was reported as within normal limits. Under general anaesthetic, the lesion was seen to be polypoid in nature with superficial necrosis. It involved the lower pole of the left tonsil and the posterior one-third of the tongue extending across the midline and measuring approximately 5 cm in diameter. A surgical biopsy was performed and the tissue obtained was reported as showing the presence of acinic cell carcinoma with necrosis. In view of the extent of the lesion, the patient was treated by radical radiotherapy. Two small parallel opposed fields were used to encompass the tumour. A total midline dose of 6,000 rads in 30 treatments over 42 days was achieved using a supervoltage cobalt machine. During treatment, the patient experienced a sore throat which was well controlled by aspirin mucilage. Apart from this, treatment was completed uneventfully. Towards the end of therapy considerable regression was noted and when seen in the out-patient department 6 weeks later no evidence of local disease could be seen or palpated. At present, he remains alive and well with no recurrence or evidence of distant disease 8 months after the finish of treatment. 423
424
D. C. FERMONT
Pathology Figures 1 and 2 show the characteristic microscopic appearances of acinic cell carcinoma in the surgical biopsy specimen. The majority of these tumours are encapsulated and definitive infiltrative growth is uncommon. They consist of solid epithelial sheets interspersed with spaces which may give rise to cribriform appearances. Glandular structures may be seen in as many as half the cases. The cells are usually polygonal and show abundant granular cytoplasm (Fig. 1) which is basophilic in most cases. Periodic acid-Schiff staining is nearly always positive (Fig. 2). Discussion Minor salivary gland acinic cell carcinoma is uncommon. Few cases are to be found in the literature. In a paper on tumours of minor salivary glands, Fine et al. (1960) included a 50-year-old white female who had a local excision and interstitial radium implant for a lesion of the tongue. The patient was alive and well 2 years later. Baden and Wallen (1965) have published a detailed case report of a 75-year-old white female with a lesion involving the floor of the mouth. This lesion was locally excised and the patient showed no recurrence at 6 months. Other cases have been mentioned in larger series mainly concerned with parotid disease and consequently lack adequate clinical information. Gorlin and Chaudhry (1957) reported a series of 17 selected cases of acinic cell carcinoma, one of which involved the tongue of a 34-year-old white male. Local recurrence
FIG. 1 Acinic cell carcinoma. Showing a tumour composed of alveoli of cells with abundant granular cytoplasm. (H. & E. x 160)
CLINICAL RECORDS
425
FIG. 2 Acinic cell carcinoma. Showing PAS positive intracytoplasmic granules. (PAS x400).
and distant metastases occurred within 4 years. However, no mention of the type of treatment was given. It is not only the rarity of this condition which is interesting but, in this case the response to radiotherapy. Generally speaking, acinic cell carcinoma is thought to be radio-resistant and the first line of treatment is usually surgical Eneroth et al (1966) treated a small group of 10 acinic cell carcinomas of the parotid gland by radiotherapy and surgery. Pre-operative radiotherapy to a total dose of 2,800-4,200 rads was given in fractions over 3-5 days using a short distance source with surgery subsequently performed 6 weeks later. High radio) sensitivity was defined as a lesion which was impalpable 6 weeks after radio-, therapy. In 3 of these cases there was clinical resolution but a small non-palpable residue was present at operation. The other 7 cases exhibited either moderate or no regression. The reason for this discrepancy is unexplained but it does suggest that some of these tumours are radio-sensitive. Experience with irradiation of acinic cell carcinoma is very limited but it seems that some of these tumours will respond, as is the case in this report, and that radiotherapy should be considered in the treatment of this condition.
Summary A case of acinic cell carcinoma involving minor salivary gland tissue is reported. This is an exceptional occurrence. The response to radiotherapy is described and it is suggested that this form of treatment should be considered in these cases.
426
D. C. FERMONT
Acknowledgements
The author would like to thank Mr. P. Abbey and Dr. P. Strickland, for permission to report this case, and Dr. M. H. Bennett, for his kind assistance with the photomicrographs. REFERENCES BADEN, E., and WALLEN, N. A. (1965) Journal of Oral Surgery, 23, 163. CHAUDHRY, A. P., VICKERS, R. A., and GORLIN, R. J. (1961) Oral Surgery, 14, 1194. ENEROTH, C. M., JAKOBSSON, P. A., and BLANCK, C. (1966) Cancer, 19, 1761. FINE, G., MARSHALL, R. B., and HORN, R. C. (1960) Cancer 13, 653.
GORLIN, R. J., and CHAUDHRY, A. P. (1957) Journal of Oral Surgery, 15, 304. Senior Registrar, The Regional Radiotherapy Centre, Mount Vernon Hospital, Northwood, Middlesex. Present address: The Meyerstein Institute of Radiotherapy, The Middlesex Hospital, London.
Acinic cell carcinoma of intraoral minor salivary gland origin By D. C. FERMONT (London)
Introduction cell carcinoma is a well-described histological entity found in salivary gland neoplasms. There have been a number of published series which have included examples of this disease affecting the major salivary glands. However, its occurrence in minor salivary gland tissue appears to be rare. An analysis of 1,414 cases of minor salivary intraoral gland tumours by Chaudhry et al. (1961), over a thirty-three-year period (1927-1960) yielded a solitary case. There appears to have been one previous detailed case report by Baden and Wallen (1965). ACINIC
Case report A 64-year-old male was referred to the E.N.T. department at his local hospital by his general practitioner. He gave a four-month history of hoarseness of voice which had become worse during the preceeding 3 weeks. He also complained of dysphagia for solids, discomfort in the left ear and an episode of haemoptysis. Examination revealed a well-nourished individual with a thick voice. Inspection of the oral cavity showed him to be edentulous. Depression of the tongue with a spatula revealed a large tumour situated posteriorly on the left side. There was no cervical lymphadenopathy. The patient was admitted for investigation and biopsy. General physical examination was unremarkable. There was no evidence of anaemia and an E.S.R. of 15 mm/hr (Westergren) was recorded. A P.A. chest x-ray was reported as within normal limits. Under general anaesthetic, the lesion was seen to be polypoid in nature with superficial necrosis. It involved the lower pole of the left tonsil and the posterior one-third of the tongue extending across the midline and measuring approximately 5 cm in diameter. A surgical biopsy was performed and the tissue obtained was reported as showing the presence of acinic cell carcinoma with necrosis. In view of the extent of the lesion, the patient was treated by radical radiotherapy. Two small parallel opposed fields were used to encompass the tumour. A total midline dose of 6,000 rads in 30 treatments over 42 days was achieved using a supervoltage cobalt machine. During treatment, the patient experienced a sore throat which was well controlled by aspirin mucilage. Apart from this, treatment was completed uneventfully. Towards the end of therapy considerable regression was noted and when seen in the out-patient department 6 weeks later no evidence of local disease could be seen or palpated. At present, he remains alive and well with no recurrence or evidence of distant disease 8 months after the finish of treatment. 423
424
D. C. FERMONT
Pathology Figures 1 and 2 show the characteristic microscopic appearances of acinic cell carcinoma in the surgical biopsy specimen. The majority of these tumours are encapsulated and definitive infiltrative growth is uncommon. They consist of solid epithelial sheets interspersed with spaces which may give rise to cribriform appearances. Glandular structures may be seen in as many as half the cases. The cells are usually polygonal and show abundant granular cytoplasm (Fig. 1) which is basophilic in most cases. Periodic acid-Schiff staining is nearly always positive (Fig. 2). Discussion Minor salivary gland acinic cell carcinoma is uncommon. Few cases are to be found in the literature. In a paper on tumours of minor salivary glands, Fine et al. (1960) included a 50-year-old white female who had a local excision and interstitial radium implant for a lesion of the tongue. The patient was alive and well 2 years later. Baden and Wallen (1965) have published a detailed case report of a 75-year-old white female with a lesion involving the floor of the mouth. This lesion was locally excised and the patient showed no recurrence at 6 months. Other cases have been mentioned in larger series mainly concerned with parotid disease and consequently lack adequate clinical information. Gorlin and Chaudhry (1957) reported a series of 17 selected cases of acinic cell carcinoma, one of which involved the tongue of a 34-year-old white male. Local recurrence
FIG. 1 Acinic cell carcinoma. Showing a tumour composed of alveoli of cells with abundant granular cytoplasm. (H. & E. x 160)
CLINICAL RECORDS
425
FIG. 2 Acinic cell carcinoma. Showing PAS positive intracytoplasmic granules. (PAS x400).
and distant metastases occurred within 4 years. However, no mention of the type of treatment was given. It is not only the rarity of this condition which is interesting but, in this case the response to radiotherapy. Generally speaking, acinic cell carcinoma is thought to be radio-resistant and the first line of treatment is usually surgical Eneroth et al (1966) treated a small group of 10 acinic cell carcinomas of the parotid gland by radiotherapy and surgery. Pre-operative radiotherapy to a total dose of 2,800-4,200 rads was given in fractions over 3-5 days using a short distance source with surgery subsequently performed 6 weeks later. High radio) sensitivity was defined as a lesion which was impalpable 6 weeks after radio-, therapy. In 3 of these cases there was clinical resolution but a small non-palpable residue was present at operation. The other 7 cases exhibited either moderate or no regression. The reason for this discrepancy is unexplained but it does suggest that some of these tumours are radio-sensitive. Experience with irradiation of acinic cell carcinoma is very limited but it seems that some of these tumours will respond, as is the case in this report, and that radiotherapy should be considered in the treatment of this condition.
Summary A case of acinic cell carcinoma involving minor salivary gland tissue is reported. This is an exceptional occurrence. The response to radiotherapy is described and it is suggested that this form of treatment should be considered in these cases.
426
D. C. FERMONT
Acknowledgements
The author would like to thank Mr. P. Abbey and Dr. P. Strickland, for permission to report this case, and Dr. M. H. Bennett, for his kind assistance with the photomicrographs. REFERENCES BADEN, E., and WALLEN, N. A. (1965) Journal of Oral Surgery, 23, 163. CHAUDHRY, A. P., VICKERS, R. A., and GORLIN, R. J. (1961) Oral Surgery, 14, 1194. ENEROTH, C. M., JAKOBSSON, P. A., and BLANCK, C. (1966) Cancer, 19, 1761. FINE, G., MARSHALL, R. B., and HORN, R. C. (1960) Cancer 13, 653.
GORLIN, R. J., and CHAUDHRY, A. P. (1957) Journal of Oral Surgery, 15, 304. Senior Registrar, The Regional Radiotherapy Centre, Mount Vernon Hospital, Northwood, Middlesex. Present address: The Meyerstein Institute of Radiotherapy, The Middlesex Hospital, London.
