Treatment of the Clinically Negative Neck in Oral Squamous Cell Carcinoma

Objective: To define the most effect treatment plan of patients with oral cavity squamous cell carcinoma with clinically negative (N0) neck staging. Study Design: Retrospective review of 54 patients with N0 neck staging who underwent resection of an oral cavity primary tumor with or without elective neck dissection between January 1982 and December 1992 and with a minimum follow-up of 3 years. Methods: The records of 54 patients with previously untreated oral cavity squamous cell carcinoma and N0 neck staging were retrospectively reviewed to determine the impact of elective neck dissection on patient outcomes including regional recurrence and overall survival. Results: All patients underwent surgical resection of their oral cavity tumors, with 33 patients undergoing “watchful waiting” observation for the development of neck disease while 21 patients had elective neck dissections. The most controversial group of patients were those with intermediate-sized (T2 and T3) primary tumors. Eighteen of these patients underwent elective neck dissection, with two patients developing recurrent neck disease and an ultimate prognosis of 72%. Twelve patients had observation of their necks, with five of these patients subsequently requiring neck dissection. An additional seven patients did not undergo neck dissection, and this group had four survivors free of disease. The prognosis was 42% in patients not having elective neck dissections. Conclusions: Tl tumors do well with neck treatment other than careful observation. The data suggest that patients with T2 and T3 oral squamous cell carcinoma should undergo surgical resection of their primary tumor site and elective neck dissection. Patients with T4 oral cavity lesions should routinely undergo neck dissection.     

Management of the N0 Neck During Salvage Laryngectomy

Background: Radiotherapy is effective treatment for laryngeal carcinoma. Early-stage laryngeal carcinoma has a low incidence of cervical metastasis. Patients initially clinically N0 usually remain N0 when they fail at the primary site. The incidence of subclinical metastasis in these patients is not well described. Watchful waiting or elective neck dissections are advocated. Objective: Examine the incidence of subclinical metastatic disease in patients undergoing elective neck dissections with salvage laryngectomy. Study Design: Prospective study (1991–1996) of patients who failed radiotherapy and underwent salvage laryngectomy with elective neck dissection. Methods: Thirty-four patients underwent salvage laryngectomy with neck dissection (30 bilateral, 4 unilateral). All were clinically N0 at initial presentation and remained N0 at recurrence. Pathologic study of the neck dissection specimens was undertaken. Patients were followed for a minimum of 2 years (mean, 4 y). Results: The male-to-female ratio was 4.5:1, with a mean age of 62 years (range, 38 to 75 y). Metastatic disease was present in 6 patients (17%); 4 of 14 (28%) supraglottis and 2 of 20 (10%) glottic. Presence of disease in the neck according to stage at recurrence was as follows: T2, 2 of 12; T3, 3 of 14; and T4, 2 of 8. Neck disease was ipsilateral in 4 and contralateral in 2 patients (both supraglottic primaries). Conclusions: Subclinical cervical metastasis may be present in N0 laryngeal carcinoma patients who have recurrence following radiotherapy. Morbidity of a lateral neck dissection is minimal, with excellent control of the neck being possible. Supraglottic and advanced glottic (T3-T4) patients may benefit the most.     

Clinical outcome following radiotherapy and planned neck dissection in N+ head and neck cancer patients

Conclusions. This study confirms earlier findings that patients with viable tumour cells in the neck after external beam radiotherapy (EBRT) have a poor prognosis. The study also indicates that neck dissection (ND) does not change the prognosis for patients with a complete clinical response in the neck. At the moment our guidelines concerning this matter are being reviewed. Objectives. The protocol at our institution stipulates a planned ND in patients with metastasis in the neck after EBRT regardless of the response in the neck. As the necessity for a planned ND has not been clarified we wanted to evaluate our results. Patients and methods. Patients diagnosed from 1998 to 2002 with metastasis in the neck who received EBRT were evaluated for histopathological findings and clinical outcome. Results. A total of 156 patients were included. Overall survival was 62% and disease-specific survival was 76%. There was a complete response (CR) in the neck in 63 patients (40%); among these 15 had viable tumour cells in the neck. In patients not achieving CR, 40% (37/93) had viable tumour cells left in the neck. Patients with viable tumour cells in the neck after EBRT had disease-specific survival of 48% compared with 90% among patients without viable tumour cells.     

Surgical treatment of the neck in cancer of the larynx

Current concepts in management of the clinically negative and clinically positive neck in laryngeal cancer are reviewed. Occult disease in the neck not detected by physical and radiographic examination may also be difficult to identify on routine histologic examination. Immunohistochemistry or molecular analysis may detect metastatic involvement not apparent by light microscopy. The surgeon should be aware of the relatively high incidence of micrometastases in patients with laryngeal cancer to establish optimal treatment approaches. Elective treatment of the neck is recommended for supraglottic tumors staged T2 or higher, and glottic or subglottic tumors staged T3 or higher. The neck may be treated electively by either surgery or irradiation, but irradiation is best reserved for cases where that modality is employed for the primary tumor. Elective neck dissection provides important information for prognostic purposes and therapeutic decisions, by establishing the presence, number, location and nature of occult lymph node metastases. The selective lateral neck dissection (levels II, III and IV), unilateral or bilateral, is the procedure of choice for elective treatment. Paratracheal nodes (level VI) should be dissected in cases of advanced glottic and subglottic cancer. Complete radical or functional neck dissections are excessive in extent, as levels I and V are almost never involved. Sentinel lymph node biopsy may fail to detect tumor on frozen section examination or may not reveal 'skip' metastases. The clinically involved neck is usually treated by complete radical or functional neck dissection of levels I through V. Selective neck dissection has been employed successfully in selected cases, particularly for N1 or occasionally N2 nodal involvement. The selective neck dissection can be extended to include structures at risk. More advanced disease has been treated in this manner often in association with adjuvant chemotherapy and/or irradiation. While the benefit of adjuvant treatment is difficult to assess, it appears most useful in cases with extranodal spread of disease, a factor associated with the worst prognosis.     

Neoangiogenesis and squamous cell carcinoma of the tongue

A tumour can only successfully propagate if it develops its own blood supply. Human cancers show a great propensity for stimulating neoangiogenesis through a variety of mechanisms. The present study investigates the relationship between neoangiogenesis, metastasis and survival in 51 patients with tongue cancer resected surgically, 26 of whom had lymph node metastases treated by radical neck dissection. The vessels were immunolabelled for CD34. Two parameters were studied: the vessel count/mm-₂ (VC) and the vessel count corrected for the relative proportions of carcinoma and stroma (VV). The data were analysed by uni variate and multivariate methods. The median VC was 35 and the VV was 103. Patients with neck node metastases tended to have a lower VV (93) than those with no metastases (114) (P = 0.0489). The tumour specific survival of the whole groups of patients was 59% (95% confidence intervals, 37–74%) and not surprisingly the patients with neck node metastases had a poorer survival than those without neck node metastases (,P = 0.0083). Cox’s proportional hazards model demon strated that patients with a low VC index tended to have a good prognosis (P = 0.0234). Previous studies of neoangiogenesis in head and neck squamous carcinoma have been limited and the present investigation suggests that VV is associated with metastases, and that VC may be an indicator of prognosis.     

Presence of activated T lymphocytes in peripheral blood of head and neck squamous cell carcinoma patients predicts impaired prognosis

Conclusions. The results indicate that a high level of peripheral blood (PB) T-lymphocyte activation in vivo predicts impaired prognosis with and without adjustment for TNM stage in head and neck squamous cell carcinoma (HNSCC). Objective. To determine if PB T-lymphocyte activation in vivo is associated with the presence of, stage of and prognosis of HNSCC. Materials and methods. Sixty-two patients with newly diagnosed HNSCC and 15 control patients were studied. PB T-lymphocyte activation was assessed by measuring by flow cytometry the percentage of PB T lymphocytes (CD3?+?) showing the early activation-related cell surface epitopes CD69+ or CD71+ (transferrin receptor) or the late activation epitopes CD25+ (IL-2 receptor) or HLA-DR+. Results. There was no significant difference in expression of T-lymphocyte activation markers between HNSCC patients and control patients, or any difference dependent on TNMG stage. In HNSCC patients a high percentage of CD71+ T lymphocytes predicted worse prognosis with a relative risk (RR) of 2.38 (confidence interval (CI): 1.04–5.47). A high mean value of the early (CD69?+?/CD71?+?) (RR 2.37; CI: 1.06–5.29) or late (CD25?+?/HLA-DR?+?) (RR 3.31; CI: 1.39–7.88) activation markers also predicted worse prognosis. Following adjustment for TNM stage, high mean value of the early activation epitopes CD71+ (RR 2.89; CI: 1.22–6.85), the mean value of CD69?+?/CD71+ (RR 2.58; CI: 1.12–5.91) and CD25?+?/HLA-DR+ (RR 2.75; CI: 1.14–6.62) predicted worse prognosis.     

MMP-14 can serve as a prognostic marker in patients with supraglottic cancer

The purpose of this study was to examine the expression of MMP-14, 15 and 16 (MT1, MT2 and MT3-MMP) in supraglottic carcinoma and to explore their clinical significance. Expression of MMP-14, 15 and 16 was examined using RT-PCR and immunohistochemistry methods in samples from 85 cases of supraglottic carcinoma. Results showed that both mRNA and protein expression of MMP-14, 15 and 16 were increased in supraglottic carcinoma tissues compared to expression in control adjacent non-neoplastic tissues (P < 0.05). Expression of MMP-14, but not MMP-15 and MMP-16, was significantly increased in the T3 and neck nodal metastasis groups compared with the T1–2 group and the group without nodal metastasis at both mRNA and protein levels (P < 0.05). Expression of MMP-14 mRNA and protein was also higher in tumors of patients with stage III–IV disease compared to patients with clinical stage I–II tumors (P < 0.05). Kaplan–Meier survival curves showed that the groups with high MMP-14 protein expression had a poorer prognosis than patients in the groups with weak or negative expression of MMP-14 protein (P < 0.05). In conclusion, MMP-14 may play an important role in the progression of supraglottic carcinoma and may be a novel prognostic factor for patients with supraglottic carcinoma. Huiyan Zhang and Ming Liu are co-first authors.     

Otolaryngologic aspects of lyme disease

Lyme disease is a systemic illness caused by the spirochete Borrelia burgdorferi and transmitted by the bite of a tick in the Iocodes ricinus complex. While the illness is often associated with a characteristic rash, erythema migrans, patients may also present with a variety of complaints in the absence of the rash. The otolaryngologist may be called upon to see both groups of patients, with any number of signs and symptoms referable to the head and neck, including headache, neck pain, odynophagia, cranial nerve palsy, head and neck dysesthesia, otalgia, tinnitus, hearing loss, vertigo, temporomandibular pain, lymphad-enopathy, and dysgeusia. We review our institutional experience with 266 patients with Lyme disease, 75% of whom experienced head and neck symptoms. We also summarize the diagnostic and treatment modalities for this illness.     

Photodynamic therapy and the treatment of head and neck neoplasia

Objective: To present the theory, technique, and results of photodynamic therapy for the treatment of oral, laryngeal, and head and neck cancers. Study Design: Retrospective review of the literature of more than 500 patients with head and neck cancer treated with photodynamic therapy, as well as a retrospective review of the author's 107 patients treated with photodynamic therapy for head and neck neoplasia between 1990 and 1997. Methods: The literature was retrospectively reviewed, as were patient records, and tabulaled for age, sex, site, and staging of lesions, with special focus on post-photodynamic therapy treatment outcome, long-term disease-free survival, and complications. Results: Twenty-five patients with carcinoma in situ and T1 squamous cell carcinoma of the true vocal cord who underwent photodynamic therapy treatment for cure obtained a complete response after a single photodynamic therapy treatment. Only one patient has had recurrence to date, with a cure rate to 79-month follow-up of 95%. Twenty-nine patients with carcinoma in situ and T1 recurrent squamous cell carcinomas of the oral cavity and tongue were treated. All obtained a complete response after a single photodynamic therapy treatment; however, five patients developed local recurrence with follow-up to 70 months, for an 80% cure rate. A review of 217 patients with early squamous cell carcinomas of the head and neck treated with photodynamic therapy in the literature demonstrated an 89.5% complete response rate. The most common complication in these patients was limited prolonged skin photosensitivity without any permanent sequelae. Conclusions: Photodynamic therapy is effective for treating carcinoma in situ and T1 squamous cell carcinoma of the larynx and oral cavity and may be of benefit as an adjuvant intraoperative treatment of stages III and IV tumors of the head and neck in conjunction with surgery and radiation therapy to improve cure rates. Further controlled studies need to be performed to further demonstrate the effectiveness of photodynamic therapy and the treatment of head and neck cancers.     

Occult metastases in cancer of the larynx and their relationship to clinical and histological aspects of the primary tumor: A Four-Year multicentric research.

The authors have tried to verify whether some clinical or pathological features of laryngeal cancer may favor the occurrence of occult metastases in the lymphnodes of the neck in No cases. The purpose of the investigation was to define the possible existence of tumors, where elective neck dissection, in the absence of palpable nodes, could be done without, thus contributing to settlement of a long debated problem. Different parameters, both clinical and pathological, have been considered. The result of a cross comparison of such parameters in 237 cases of cancer of the larynx without palpable nodes, submitted to surgery on the primary and elective neck dissection, indicates that, although the frequency of occult metastases is significantly related to the site and size of the tumor, its grading, and the degree and type of stromal reaction, the favorable concurrence of all said parameters occurs in 2% of cases only. However, if only clinical parameters, viz. site and size of tumor, are taken into account, a favorable concurrence occurs in 18% of cases with an incidence of occult metastases lower than 2%. These cases are almost exclusively represented by T1No supraglottic and T2N0 glottic tumors. We can conclude by saying that clinical and pathological preoperative findings may offer a useful clue in evaluating the risk of occult metastases, and hence advising, or not, an elective neck dissection in No cases. Nevertheles, in the vast majority of cases, an elective functional neck dissection still offers the best guarantee of oncologic safety while avoiding unnecessary mutilation.     

Immunohistochemical detection of cervical lymph node micrometastases from T2N0 tongue cancer

Conclusions

These results indicate that extensive, multiple cervical micrometastases occurred from an early stage in patients with T2N0 tongue cancer. The presence of micrometastases suggests the necessity of preventive neck dissection for Level I–IV nodes as a radical treatment.

Objective

Cervical lymph node metastases occur with a relatively high frequency in patients with T2N0 squamous cell carcinoma of the tongue, and control of the metastases greatly influences the prognosis of patients. In this study, micrometastases in the cervical lymph nodes were investigated to clarify the necessity and required extent of preventive neck dissection.

Material and methods

We investigated micrometastases in 24 subjects who had previously been diagnosed with T2N0 tongue cancer. We performed immunostaining with anti-cytokeratin antibody cocktail AE1/AE3 of sections of 401 paraffin-embedded lymph nodes obtained from these patients.

Results

Micrometastases were observed in 14 patients (58%) and were most abundant in Level II nodes (n=11; 46%). Micrometastases were observed in the Level IV nodes of 3 patients (13%), and upstaging to pN2b occurred in 7 patients (29%).     

Nodal disease in purely glottic carcinoma: Is elective neck treatment worthwhile?

Objective: Although there is a generalized understanding of the relatively low overall incidence of nodal disease from purely glottic carcinoma, the exact role for elective neck treatment in the management of this disease remains controversial. The purpose of this study was to identify the incidence of occult nodal disease (including paratracheal) in patients who have glottic carcinoma without significant extra-glottic extension and to identify which patients are at risk for this. A retrospective chart review of 92 such patients who had either undergone neck dissection or been observed for a minimum of 2 years was performed. Results: For the 92 patients, neck treatment consisted of observation in 68 patients, paratracheal node dissection in four, unilateral neck dissection in four, unilateral neck dissection and excision of paratracheal nodes in 14, and bilateral neck dissection with paratracheal node excision in two. Of the 24 nodal dissections performed, four were positive for occult metastatic disease. No patient in the observation group developed nodal disease. Conclusion: The incidence of occult nodal disease in NO glottic carcinoma is low, 0% in early stage disease (T1–T2) and 19% in late stage disease (T3–T4). Nodes at highest risk included only the paratracheal, level II, and level III. Elective neck treatment should only be undertaken for advanced (T3–T4) disease and even then is of questionable benefit. If undertaken, it should have a low potential morbidity, such as selective neck dissection or radiation. Computed tomography was not useful in staging the neck for this subset of patients.     

Platelet Aggregation in Head and Neck Tumors in China

We measured the maximum aggregation rate (MAR) of platelets in 770 patients with malignant head and neck tumors, 55 patients with benign tumors of the head and neck, and 164 healthy people as a control group. The results were as follows:1. the mean MAR value of patients with malignant tumors was significantly higher than the control group mean value; 2. prior to treatment, the mean MAR value increased with advancing tumor stage;3. both MAR values of relapsed or metastasized patients and of nonsurvivors in stage III and IV increased significantly compared with survivors or patients recovering from malignant tumors. The results of the present study suggest that MAR values of patients with malignant tumors of the head and neck may serve as indicators in evaluating therapeutic procedures and prognosis.     

Management of the N0 neck in patients with laryngeal squamous cell carcinoma

Abstract

Background: Neck lymph node status is the chief prognostic index in patients with head and neck squamous cell carcinoma (SCC), yet the management of a clinically negative neck in this setting is still controversial, especially in patients with laryngeal SCC (LSCC).

Objectives: To evaluate the efficacy of selective neck dissection (SND) to control occult disease in patients with LSCC and clinically negative (cN0) necks.

Materials and methods: Medical records of 1476 patients with cN0 LSCC were analyzed. In conjunction with primary treatment, 126 (8.5%) underwent at least unilateral elective neck dissection, whereas most 1350 (91.5%) followed a wait-and-see protocol. Prognostic significance was indicated by the Kaplan–Meier survival estimates.

Results: The rate of occult neck disease was 15%. Five-year overall and disease-free survival rates were 74.4% and 66.7%, respectively. Prognosis was closely related to T stage, preoperative tracheotomy, and postoperative recurrence. There was no significant correlation with age, sex, or preoperative neck dissection; but in patients with supraglottic LSCC, the relation between prognosis and preoperative neck dissection was significant, with fewer neck and local recurrences than the wait-and-see group (p?<?.05).

Conclusions and significance: Selective neck dissection is serving as an accurate prognostic tool in patients with supraglottic laryngeal cancers.     

Neck metastasis in patients with T1-2 supraglottic cancer

Objectives

Unlike glottic cancer, supraglottic cancer often presents with neck metastases. This different might be attributable to the location of the primary lesion. This study aimed to clarify the relationships between the sublocation of T1-2 supraglottic cancer, human papillomavirus (HPV) infection, neck metastasis, and prognosis of supraglottic cancer.

Occurrence of lymph node metastasis in early-stage parotid gland cancer

Lymph node metastasis is one of the most important factors in therapy and prognosis for patients with parotid gland cancer. Nevertheless, the extent of the primary tumor resection and the necessity of a neck dissection still is a common issue. Since little is known about lymph node metastasis in early-stage parotid gland cancer, the purpose of the present study was to evaluate the occurrence of lymph node metastases in T1 and T2 carcinomas and its impact on local control and survival. We retrospectively analyzed 70 patients with early-stage (T1 and T2) primary parotid gland cancer. All patients were treated with parotidectomy and an ipsilateral neck dissection from 1987 to 2009. Clinicopathological and survival parameters were calculated. The median follow-up time was 51.7 months. A positive pathological lymph node stage (pN+) was found in 21.4% of patients with a significant correlation to the clinical lymph node stage (cN) (p = 0.061). There were no differences in the clinical and histopathological data between pN− and pN+ patients. In 73.3% of pN+ patients, the metastases were located intraparotideal. The incidence of occult metastases (pN+/cN−) was 17.2%. Of all patients with occult metastases, 30.0% had extraparotideal lymphatic spread. A positive lymph node stage significantly indicated a poorer 5-year overall as well as 5-year disease-free survival rate compared to pN− patients (p = 0.048; p = 0.011). We propose total parotidectomy in combination with at least a level II–III selective neck dissection in any case of early-stage parotid gland cancer.     

Foxp3 expression in lymph node metastases in patients with head and neck cancer

Introduction: The prevalence and activity of regulatory T cells in patients with cancer correlates with poor prognosis. These cells are characterized by their expression of Forkhead box protein-3 (Foxp3). Squamous cell carcinoma is the most prevalent type of cancer in the head and neck region with overall poor survival rates, also due to early spread of metastatic cells.

Material and methods: Primary tumor specimens as well as lymph node specimens harvested during neck dissection of 65 patients with a diagnosis of HNSCC were subjected to immunohistochemical and H-score analysis of Foxp3 expression. Demographics, diagnoses, histopathology and subsequent outcome were analyzed.

Results: The primary cancer was squamous cell carcinoma in all patients (male/female 55:10) with the following tumor locations: oral cavity n?=?16, oropharynx n?=?28, hypopharynx n?=?11 and larynx n?=?10 (Stage III n?=?18; Stage IVA n?=?45; Stage IVB n?=?2). The H-score for Foxp3 expression in the primary lesion as well as metastatic lymph nodes was significantly higher in advanced stages compared to early stages with differences among tumor locations, which were not significant. High Foxp3 expression was associated with inferior overall survival rates at a mean follow-up of 83.4 months (6–204 months)

Conclusions: Foxp3 expression in HNSCC varied from the anatomical site and correlated positively with tumor stage and was associated with poor prognosis. Therefore, Foxp3 expressions in primary lesions as well as lymphogenic metastases appear to predict high-risk HSNCC patients. Novel therapeutic approaches targeting Foxp3⁺ cells might seem promising for this patient population.     

Osteosarcoma of the Head and Neck: Meta-analysis of Nonrandomized Studies

To assess the role of adjuvant therapy in the treatment of osteogenic sarcoma of the head and neck, treatment and survival information from 173 patients with osteosarcoma of the head and neck was entered into a database. A meta-analysis of the data was attempted with primary emphasis on the effect of adjuvant therapy on disease outcome. The overall 5-year survival was 37%. Patients with mandibular and maxillary tumors had similar survival rates; both groups fared significantly better than patients with extragnathic tumors (P<0.001). Treatment with surgery alone was associated with significantly longer survival rates (P<0.03) than surgery with adjuvant therapy. In the majority of patients reported, information about surgical margins was not available. For this reason, the differences may not adequately represent the effect of adjuvant therapy. While there have been encouraging results with adjuvant treatment protocols for long bone osteosarcoma, the ultimate role of radiation and chemotherapy in the management of osteosarcoma of the head and neck remains unproven. Nevertheless, we recommend that adjuvant therapy be considered due to the poor prognosis in osteosarcoma of the head and neck.     

Ethmoid sinus cancer: Results of treatment with surgery and combined therapy

Objective—Ethmoid sinus cancer is a rare paranasal sinus malignancy. Its characteristics include a low incidence rate, a great variety of histopathological types and multiple treatment modalities. Currently, there remains no definite consensus regarding its optimal management. The aim of this study was to examine the outcome of a population of Asian patients with advanced ethmoid sinus cancers that had been treated with surgery plus combined therapy.

Material and Methods—Between January 1989 and December 2002 inclusive, 19 newly diagnosed patients with ethmoid sinus cancers who had undergone surgical intervention were enrolled, T4 being the principal carcinoma stage (68.4%). All participating cases proved to be node-negative and no evidence of any distant metastasis was detected at the time of diagnosis. The major treatment modality was surgery plus postoperative radiotherapy. All but 2 of the 13 patients with T4 cancer underwent craniofacial resection with pericranial flap reconstruction.

Results—The estimated overall and disease-free survival rates 3 years post-treatment were 49.4% and 26.3%, respectively. Local tumor recurrence was more common than regional recurrence and/or distant metastasis. A total of 5/15 T3–T4 patients (33%) developed a neck metastasis, 3 of whom also suffered a distant metastasis. There was no postoperative mortality for the cases treated with craniofacial resection.

Conclusions—Ethmoid sinus cancer typically demonstrates a propensity for late diagnosis and poor prognosis. This study confirms that craniofacial resection plus combined associated therapy is the optimal approach for the effective management of extensive ethmoid sinus tumors and is associated with an acceptable morbidity rate. More aggressive disease management featuring prophylactic concurrent chemoradiotherapy including neck or elective neck dissection plus chemotherapy should be considered for T3–T4 patients as opposed to T1–T2 patients.     

Angiosarcoma of the Submandibular Salivary Gland: Case Report and Review of the Literature

Objective The purpose of this report is to describe an example of angiosarcoma (AS) of the submandibular salivary gland. The clinical and immunohistopathologic features of these lesions are also reviewed.

Material and Methods A 17-year-old male high school student was admitted to our clinic with a 1-year history of a slow-growing, tender mass in the left submandibular region. Physical examination on initial presentation revealed a diffuse soft tissue mass 6 cm in diameter involving the left submandibular region. MRI analysis revealed a mass located superolateral to the submandibular salivary gland, measuring 4.0 x 2.0 cm². The mass was excised completely together with the left submandibular salivary gland. Histopathologic analysis led to a diagnosis of AS. Immunohistochemical studies were also used to determine endothelial cell differentiation. Owing to the lateralized nature of the lesion, a left functional neck dissection was performed and postoperative radiotherapy was planned.

Results AS is a malignant tumor of endothelial cell origin that may occur in any region of the body. The commonest sites include the extremities and the retroperitoneal space, with only 4% of AS tumors arising in the head and neck area. The submandibular salivary gland is an extremely rare location for this tumor. Based on a literature review, this case report represents only the second reported case of AS of the submandibular salivary gland.

Conclusion In most cases, radical surgery and postoperative radiotherapy are advocated to treat patients with AS tumors, with lymph node clearance recommended in cases of lateralized lesions In some patients, distant metastasis may occur after many years, which necessitates long-term follow-up. The prognosis is poor in most cases of AS.