Carcinoma Of Minor Salivary Glands Research Articles

Long-term treatment outcome of minor salivary gland carcinoma of the hard palate

Minor salivary gland carcinoma of the hard palate is rare, and its long-term survival rate is high, making it difficult to evaluate the prognostic factors and the efficacy of treatment. This study was designed to evaluate the treatment outcome of minor salivary gland carcinoma of the hard palate. 103 cases of minor salivary gland carcinoma of the hard palate treated with surgery alone or underwent surgery combined with post-operative radiotherapy hospitalized in Cancer Center, Sun Yet-Sen University, from 1968 to 2008 were reviewed retrospectively. The most common histologic types were adenoid cystic carcinoma in 48 patients(46.6%), mucoepidermoid carcinoma in 37(35.92%), malignant mixed tumor in 15(14.56%), and acinic cell carcinoma in 3(2.91%). The median follow-up time was 74.83 months (range 0.9-356.57 months). Overall outcomes at 5 and 10 years were overall survival (OS), 77.9% and 65.7%; recurrence-free survival (RFS), 64.4% and 53.2%; and disease specific survival (DSS), 77.9% and 67.7%, respectively. There was no significant difference in overall survival (P=0.52), recurrence-free survival (P=0.762) and disease specific survival (P=0.449) between patients who underwent surgery alone and those who underwent surgery plus post-operative radiotherapy. Surgery has been accepted as the primary treatment for minor salivary gland carcinoma of hard palate. Sufficient surgical excision with adequate margins is essential for a favorable outcome. We advocate using radiotherapy in the post-operative context for patients with poorly differentiated, cervical lymph node metastasis, positive or close margins, and large primary lesions.

Acinic Cell Carcinoma of Minor Salivary Gland of the Base of Tongue That Required Reconstructive Surgery

Acinic cell carcinoma of minor salivary gland of the base of tongue is very rare. Squamous cell carcinoma is the most common tumor in the base of tongue. We present a patient with gigantic acinic cell carcinoma of the base of tongue. This patient required emergency tracheotomy before surgery, because he had dyspnea when he came to our hospital. We removed this tumor by pull-through method and performed reconstructive surgery using a rectus abdominis myocutaneous flap. It was a case that to preserved movement of the tongue and swallowing function by keeping lingual arteries and hypoglossal nerves. This case was an extremely rare case of ACC of the base of tongue that required reconstructive surgery.

A clinical study on 45 cases of intraoral minor salivary gland carcinoma

2001年4月から2011年3月までに当科で加療した口腔内小唾液腺癌45例の臨床的検討を行った。原発部位は，頬粘膜が13例と最も多く，次いで8例の口底であった。病期は，stage I 16例，stage II 13例，stage III 3例，stage IVA 12例，stage IVB 1例であった。病理組織学的には，粘表皮癌が最も多く22例で，次いで腺様嚢胞癌13例，多型低悪性度腺癌4例の順に多かった。初回治療として，放射線療法を施行した1例を除く44例に手術療法を施行した。原発巣再発は粘表皮癌4例，腺様嚢胞癌1例，腺癌NOS 1例に認めた。原発巣再発を認めた粘表皮癌4例のうち，高悪性度は2例（40.0%），中悪性度は1例（20.0%），低悪性度は1例（9.1%）で，追加手術により中悪性度・低悪性度の2例は救済された。頸部郭清術は16例に施行し，頸部再発は高悪性度および中悪性度粘表皮癌に1例ずつ認め，追加手術により中悪性度症例は救済された。原発腫瘍・頸部が制御された上で肺転移を認めた症例は腺様嚢胞癌の3例で，いずれも原病死した。小唾液腺癌45例の5年および10年疾患特異的生存率は90.1%および66.9%であった。以上より，原発巣再発の多い高悪性度粘表皮癌では十分な安全域の設定が必要であり，腺様嚢胞癌においては肺転移に対する新規治療法の確立が必要と考えられた。

HPV infection and p16 expression in carcinomas of the minor salivary glands

The correlation between p16 upregulation and high-risk HPV infection is well known in head and neck squamous cell cancer. However, no information is available on rare carcinomas of the minor salivary glands. We analyzed 38 samples of minor salivary gland malignancies. p16 expression was determined by immunohistochemistry, HPV DNA by using in situ hybridization to detect low (type 6 and 11) and high (type 16 and 18) risk HPV types. In 71% of samples p16 expression was found. Low-risk HPV DNA could not be detected in any of the samples, whereas high-risk HPV DNA was found in two samples of mucoepidermoid carcinoma, which also showed the highest immunoreactivity with p16. HPV infection does not seem to be a common event in minor salivary gland carcinoma. Upregulation of p16 is present in the majority of cases but only diffuse staining correlates with HPV 16 and 18 infections.

A comparison of the demographics, clinical features, and survival of patients with adenoid cystic carcinoma of major and minor salivary glands versus less common sites within the Surveillance, Epidemiology, and End Results registry

The scientific literature to date lacks population-based studies on the demographics, clinical features, and survival of patients with adenoid cystic carcinoma (ACC) of different anatomic sites. The authors identified 5349 patients who had ACC of the major salivary glands (N = 1850), minor salivary glands (N = 2077), breast (N = 696), skin (N = 291), lung and bronchus (N = 203), female genital system (N = 132), and eye and orbit (N = 100) from the Surveillance, Epidemiology, and End Results (SEER) registry. Differences in demographics, clinical features, and survival of patients were assessed. ACC of the eye and orbit was associated with younger age at presentation (mean age,49.9 years). ACC of the skin or breast tended to present with less aggressive prognostic features, whereas ACC of the lung and bronchus or eye and orbit tended to present with more aggressive prognostic features. In a multivariate survival analysis of patients who presented with localized disease, patients with ACC of the breast (hazard ratio [HR], 0.40) or skin (HR, 0.40) had a significantly lower risk death than patients with ACC of the major salivary glands; whereas patients with ACC of the lung and bronchus (HR, 3.72) or the eye and orbit (HR, 3.67) had a significantly higher risk. For patients who presented with regional disease, the only clear prognostic difference in multivariate analysis was that patients with ACC of skin fared significantly better. The demographics and clinical features of patients with ACC differ by disease site. The current results indicated that site may be an important predictor of survival for patients who present with localized disease but is less important for patients who present with regional disease.

Recent advances in adenoid cystic carcinoma of minor salivary gland

腺样囊性癌(adenoid cystic carcinoma,ACC)一直被认为是一种良性涎腺肿瘤,1943年,Dockerty和Mayo才强调了该肿瘤的恶性本质[1].不同部位的ACC发病率、年龄、性别甚至生物学行为上均有一定差异[2-3],大涎腺的ACC由于病例数相对较多已经得到了关注,而大涎腺外的ACC较为少见,人们对其研究较少,在此作者复习了相关文献并分别按部位综述如下。

Salivary gland carcinoma in Denmark 1990–2005: Outcome and prognostic factors: Results of the Danish Head and Neck Cancer Group (DAHANCA)

To describe outcome and prognostic factors in a national Danish series of patients treated for salivary gland carcinoma. From three Danish nation-wide registries and supplementary patient records, 871 patients diagnosed with primary major or minor salivary gland carcinoma in the period from 1990 to 2005 were identified. A total of 796 (91%) histological specimens were revised according to the WHO 2005 classification. The median follow-up time was 78 months. Three hundred and thirty-four patients (38%) experienced recurrence. Crude survival, disease-specific survival and recurrence-free survival after 5 and 10 years were 66%, 76%, 64% and 51%, 69%, 58%, respectively. In multivariate analysis age, latency, stage, microscopic margins, vascular invasion and histological grade were all independent prognostic factors with regards to crude and disease-specific survival. Stage, microscopic margins, vascular invasion and histological grade were independent prognostic factors for recurrence-free survival. Age over 61 years, latency under 8 months, stage 3+4 disease, involved or close microscopic margins, vascular invasion and high histological grade are all independent prognostic factors with a negative impact on survival in salivary gland carcinoma patients. This knowledge can be helpful in guiding clinicians in daily work and choice of treatment across the large variety of salivary gland carcinoma subtypes.

Role of positron emission tomography in management of sinonasal neoplasms—a single institution's experience

ObjectiveThe objective of the study is to examine the utility of positron emission tomography (PET) for staging and restaging after treatment of paranasal sinus carcinomas. Study designRetrospective data review was done. Subjects and methodsPatients selected underwent PET for sinonasal neoplasms from 2003 to 2008 at a tertiary care referral center. ResultsSeventy-seven scans were reviewed from 31 patients. The pathologies included olfactory neuroblastoma (n = 9), squamous cell carcinoma (n = 6), sinonasal undifferentiated carcinoma (n = 6), sinonasal melanoma (n = 6), and minor salivary gland carcinomas (n = 4). The positive predictive value of studies performed for restaging at the primary, neck, and distant sites were 56%, 54%, and 63%; negative predictive values were 93%, 100%, and 98%, respectively. During restaging, 32% of patients were accurately upstaged secondary to neck or distant site involvement. ConclusionPositron emission tomography serves as a useful adjunct to conventional imaging in the management of sinonasal malignancies. Negative studies are effective in predicting absence of disease as seen in the consistently high-negative predictive values. Positive studies need to be viewed cautiously given the high rate of false-positive studies. When viewed in conjunction with clinical examination, endoscopic assessment, and focused biopsies, they may effectively result in a more accurate assessment of the extent of disease.

Carcinome hyalinisant à cellules claires du maxillaire

Hyalinizing clear cell carcinoma (HCCC) of minor salivary glands (MSG) is a rare low-grade malignant neoplasm accounting for less than 1% of all salivary gland tumors. It usually affects the palate and the base of the tongue, and more rarely the parotid gland. We report a very rare maxillary localization. A 48-year-old male patient, without prior medical history, was referred to us for a painless gingival lesion of the right maxilla, extending from tooth 14 to 17, having appeared a few months before. The clinical examination was otherwise normal. Biopsy proved the diagnosis of HCCC. The CT scan revealed extension in maxillary sinus with bone osteolysis, and suspicion of cervical lymph nodes metastasis. The treatment was subtotal maxillectomy, cervical lymph node dissection, and postoperative radiotherapy because of incomplete bony resection. HCCC localization in the maxilla is extremely rare. This tumor may recur. The risk of metastasis is low; it concerns mainly lymph nodes. There is no treatment protocol consensus because the tumor is rare. Nevertheless, a wide local excision, with or without postoperative radiotherapy, seems to be the gold standard treatment.

Carcinoma mucoepidermoide de glândulas salivares menores

INTRODUÇÃO: Os carcinomas mucoepidermoides (CME) representam cerca de 5% de todos os tumores das glândulas salivares. Trata-se de uma lesão agressiva e deve ser considerada como hipótese de diagnóstico em lesões proliferativas da mucosa oral. O diagnóstico precoce e o correto manejo dessa neoplasia são fatores determinantes do prognóstico. Ressecção local ampla e eventualmente a radioterapia pós-operatória são o tratamento de escolha. OBJETIVO: Relatar o caso de uma paciente com carcinoma mucoepidermoide de cavidade oral, exteriorando-se pela boca, sendo submetida a exérese cirúrgica e radioterapia, evoluindo para óbito no quarto mês do início do tratamento. RELATO DO CASO: CT, 47anos, branca, foi encaminhada ao serviço de ORL do HSJA após episódio de sangramento importante em cavidade oral. Relatou o surgimento de uma massa com crescimento rápido e expansivo em topografia de fossa canina há +/- 06 meses, associado a emagrecimento de 10 kg. Paciente desidratada, hipocorada, apresentando tumoração pediculada de +/- 06 cm, consistência firme, indolor à palpação, sangrante. Etilista e tabagista crônica. Linfonodos cervicais não palpáveis. Diante do caso optou por fazer a ressecção cirúrgica do tumor e realizar o exame histopatológico que confirmou carcinoma mucoepidermoide de glândulas salivares menores. A paciente foi encaminhada ao serviço de radioterapia; porém, abandonou o tratamento e evoluiu com óbito 4 meses após. COMENTÁRIOS FINAIS: Neste caso, o crescimento rápido e agressivo da lesão, o tamanho do tumor e o abandono do tratamento proposto foi determinante no prognóstico da paciente.

Prognostic factors in patients with minor salivary gland carcinoma of the oral cavity and oropharynx

This study was performed to define prognostic factors and management of minor salivary gland carcinoma of the oral cavity and oropharynx . Retrospective analyses of patients with salivary gland carcinoma of the oral cavity or oropharynx, treated in 1989 to 2006. Statistics included univariate analyses to identify prognostic factors associated with disease-free survival (DFS) and disease-specific survival. A multivariate analysis model was constructed by the Cox method. Seventy-seven patients constituted our cohort. Significant prognostic factors regarding DFS and disease-specific survival in univariate analyses comprised tumor size, surgical margins, grade, lymph node status, and Karnofsky status and T classification. A multivariate model identified tumor size, grade, surgical margins, and lymph node status significant regarding DFS. Tumor size, grade, surgical margins, and lymph node status could be used for a rational design of treatment strategies in these rare tumors.

Acinic Cell Carcinoma of Minor Salivary Glands: A Clinical and Immunohistochemical Study

Acinic cell carcinoma is a rare malignant tumor of salivary glands. The purpose of this study is to evaluate the clinical outcome of acinic cell carcinoma in a group of 11 patients, who were treated in our clinic, and to discuss the management as well as the immunohistochemical features and prognosis of this carcinoma. The study included 11 patients with acinic cell carcinoma of the minor salivary glands who were treated in our clinic. The patients were 7 women and 4 men. The patients' age ranged from 46 to 83 years. The distribution of the primary sites was buccal mucosa (4) maxilla/maxillary sinus, etc, (2), hard palate (1), junction of soft/hard palate (1), lower lip (1), labio marginal sulcus (1), and vestibular sulcus and mandible (1). All patients were treated with surgery. Adjuvant radiotherapy was used in 3 patients. Immunohistochemical assay of expression of Ki-67, p53, EGFR, and c-erbB-2/neu markers was performed on specimens of all tumors. The mean follow-up range was 2 to 15 years. Of the 11 patients, 7 were alive (2, 3, 4, 5, and 15 years after the initial therapy). Two patients died of another cause free of the disease 9 and 10 years after the initial treatment, and 2 patients died of the disease (local recurrence, distant metastases 2 and 3 years later). Overexpression of immunohistochemical markers was evident for tumors with widespread metastases. Acinic cell carcinoma is a rare malignant tumor of the salivary glands, characterized by an indolent clinical course with the potential for both local recurrence and distant metastases. The immunohistochemical analysis of proliferation markers provides additional prognostic information for this tumor.

Acinic Cell Carcinoma of Minor Salivary Glands: A Clinicopathologic Study of 21 Cases

Acinic cell carcinoma (ACC) is an infrequent type of malignant salivary gland tumor. Approximately 16% of all ACCs occur in the mouth according to several small studies. This study was undertaken to 1) report on the clinicopathologic characteristics of 21 intraoral examples, 2) reconfirm the reported indolent behavior of these tumors, and 3) verify the synchronous or metachronous occurrence of other malignancies with ACC. Twenty-one patients with intraoral ACC were identified in the previous 27 years. Demographic data and histomorphologic characteristics were evaluated and follow-up information was sought. Fifteen patients (68%) were male and 6 female. Seven cases (33.3%) occurred in the buccal mucosa, 6 in the palate (28.6%), 5 involved the upper lip (23.8%), 2 the retromolar mucosa (9.5%), and 1 the lower lip (4.8%). The mean age of patients was 50 years, with the youngest being 13 and the oldest 73. The duration was known in 9 patients and varied from 4 months to longer than 15 years. The size of the tumors varied from 0.6 to 1.6 cm. Where reported, lesions were asymptomatic. Histologically, different patterns that included microcystic, papillary cystic, follicular and solid, and combinations of these types characterized the lesions. Follow-up information was obtained in 12 patients. Eleven patients did not report recurrence or metastatic disease. The follow-up extended from 10 months to 17 years. One patient had 2 recurrences due to erroneous diagnosis that led to inappropriate treatment. After properly diagnosed and treated, this patient has been free of tumor for 4 years. Of interest were the metachronous occurrence of lymphoma in 1 patient and the synchronous occurrence of renal cell carcinoma in another. This study confirms the indolent behavior of ACC of minor salivary glands and previous reports on the occasional synchronous or metachronous association of malignant salivary gland tumors with other malignancies.

Survival in oral cavity minor salivary gland carcinoma

Objective To describe the epidemiology and comparative survival for minor salivary gland cancer of the oral cavity. Study Design Historical cohort study. Setting Academic medical center. Subjects and Methods Cases of minor salivary gland cancer of the oral cavity were extracted from the Surveillance, Epidemiology, and End Results database (1988-2005) and staged. Kaplan-Meier survivals were compared according to histology as well as T stage and N stage. A Cox proportional hazards model incorporating histology, T stage, N stage, age, and sex was analyzed. Results A total of 639 salivary gland cancers of the oral cavity (55% female; mean age, 56 years) were identified with complete staging information, consisting of 318 mucoepidermoid, 169 adenoid cystic, 139 adenocarcinoma, and 14 acinic cell cancers. The hard palate and gums were the most common subsites involved (87.6%), followed by lip (7.2%) and tongue (5.2%). At presentation, T1 and T4 tumors predominated (42.6% and 35.2%, respectively); 93.4 percent were N0. Overall mean survival (months) was 157.9 and was similar across histologic subtypes: mucoepidermoid (172.4), adenoid cystic (141.4), acinic cell (138.7), and adenocarcinoma (147.2). Survival for low- and intermediate-grade mucoepidermoid carcinoma (171.0 and 182.3, respectively) was better than survival for high-grade mucoepidermoid carcinoma (50.3, P < 0.001). On multivariate analysis, N stage ( P < 0.001) was the most powerful predictor of survival, along with T stage ( P = 0.013), age ( P < 0.001), and sex ( P < 0.001). Conclusion T stage and N stage are the most powerful predictors of survival in minor salivary gland carcinoma of the oral cavity. With the exception of high-grade mucoepidermoid carcinoma, survival for these lesions is generally favorable.

Myoepithelial carcinoma of intraoral minor salivary glands: a clinicopathological study of 7 cases and review of the literature

Myoepithelial carcinoma (MC), also known as malignant myoepithelioma, is a rare malignant salivary gland neoplasm with a predilection for the parotid gland. We present the clinicopathological and immunohistochemical features of 7 cases of intraoral MC in attempt to better understanding this entity. Seven intraoral MCs were retrieved from the files of the Department of Oral Pathology, School of Stomatology, Wuhan University, during a 10-year period. Immunohistochemical markers, including cytokeratin (CK) AE1/AE3, S100, vimentin, smooth muscle actin (SMA), p63, and maspin, were used to further characterize these lesions. A review of contemporary relevant literature is also provided. The patients were 5 women and 2 men, and the age range was 37 to 75 years (mean 57.9 years). Three cases arose in the hard palate, 2 in the retromolar region, and 1 each in the tongue and the floor of the mouth. Histologically, the tumors exhibited a solid architecture with cells arranged in nodules, nests, trabeculae, or cords. The epithelioid cell type is the most frequently encountered, followed by clear cells. The tumor-associated matrix is more prevalent hyalinized than myxoid. Immunohistochemically, CK AE1/AE3, S100, vimentin, p63, and maspin were expressed in all cases. Positivity for SMA was seen in 3 tumors. Five patients with follow-up information showed no evidence of disease after a mean follow-up of 69.6 months (range 22-108 months). Combining the current series with 21 additional cases in the literature indicated that myoepithelial carcinoma of intraoral minor salivary glands is generally a low-grade malignant tumor with little propensity for regional or distant metastasis and low recurrence. Awareness of the clinicopathological and immunohistochemical features of intraoral MC is necessary for accurate diagnosis. Wide local excision with tumor-free margins is the treatment of choice.

Prognostic Significance of Bax and Bcl-2 Expressions in Adenoid Cystic Carcinoma of Major and Minor Salivary Glands of Nasal and Oral Epithelium~!2009-05-07~!2009-12-08~!2010-04-23~!

Prognostic Significance of Bax and Bcl-2 Expressions in Adenoid Cystic Carcinoma of Major and Minor Salivary Glands of Nasal and Oral Epithelium~!2009-05-07~!2009-12-08~!2010-04-23~!

Malignant minor salivary gland tumors: a retrospective study of 27 cases

Malignant tumors of the intra-oral minor salivary glands are uncommon. The aim of this study was to give information concerning the clinical features of these tumors, the distribution of location, treatment opportunities, and outcome. Twenty-seven patients with malignant salivary gland tumors that were treated between January 1999 and December 2008 were evaluated retrospectively. Of the 27 minor salivary gland carcinomas, 48.1% were adenoid cystic carcinomas (ACC), 29.7% mucoepidermoid carcinomas (MEC), 22.2% adenocarcinomas (ADCA). The most common first symptom was a painless swelling in 60% of the cases, with the second most common symptom being ulcers (28%). Four recurrences and two metastases were found. No recurrence was observed in ADCA. All four patients experiencing a recurrence developed it in the first 3years after treatment. Wide excision with a clinical margin of 1cm and in large tumors, positive surgical margins or perineural infiltration and postoperative radiotherapy (RT) can be recommended; but in order to give exact information concerning the possible benefit from postoperative RT, it needs large prospective multicenter studies. Long-term follow-up controls and in particularly longer than 5years in ACC including yearly chest X-rays should be offered to these patients because of late metastasis and recurrences.

Low-Grade Mucoepidermoid Carcinoma of the Intraoral Minor Salivary Glands With Cervical Metastasis: Report of 2 Cases and Review of the Literature

Low-Grade Mucoepidermoid Carcinoma of the Intraoral Minor Salivary Glands With Cervical Metastasis: Report of 2 Cases and Review of the Literature

Adenoid cystic carcinomas of minor salivary glands

Objectives Adenoid cystic carcinoma (ACC) is a very rare epithelioid tumor with different prognostic factors relating to overall survival. This study aims to analyze the prognostic factors, outcome and the value of surgical therapy on recurrent disease. Materials and methods From 1992 to 2006, a total of 33 patients with ACC originating in minor salivary glands of the oral cavity were clinicopathologically reviewed. Clinical and histological data was analyzed by univariate analysis using the log-rank test. Results 64% of patients had a low-grade and 36% had a high grade disease. The 2-, 5- and 10-year survivals were 89.7%, 62.1% and 54.2%. The T category ( p = 0.001), N category ( p = 0.027), UICC stage ( p < 0.0001), and resection margins ( p = 0.024) influenced survival. Salvage treatment influenced patient's overall survival ( p = 0.002). Conclusion This study confirms that in ACC T category, N category, UICC stage, and resection margin status correlates well with prognosis. Salvage surgery of patients with recurrent ACC should be performed if possible as the survival is significantly increased.

Characteristics of Head and Neck Cancer Patients Referred to an Oral and Maxillofacial Surgeon in the United States for Management

The purpose of this study was to report the characteristics of patients with head and neck cancer, excluding cutaneous malignancies, referred to an oral and maxillofacial surgeon in the United States for management. We performed a retrospective chart review of all head and neck cancer patients referred to the senior author's oral and maxillofacial surgery practice over 12 consecutive months. Data were extracted from the patients' comprehensive record and included demographics, social history, site, histologic diagnosis, staging, treatment, and referral patterns. A total of 90 patients, 51 men and 39 women (male-female ratio, 1.3:1), with a mean age of 64.4 years (range, 32-91 years) were referred with head and neck cancer, excluding skin cancer, over the 12-month period and were included in the study. Regarding ethnicity, 88.8% of the patients were white, 11.1% African American, and 1.1% Asian. Most of the patients, 84.4%, were referred from within the state, but only 21.1% of these resided within the metropolitan area of the senior author's practice. Of the patients in the study population, 95.5% had either private or state-provided/federally provided insurance. Social history showed that 59.9% of patients were current or past smokers, 31.1% were nonsmokers, and 8.8% were smokeless tobacco users, and only 18.8% admitted to alcohol use. Approximately 80% of patients were initially evaluated by a general dentist, oral and maxillofacial surgeon, or periodontist, and 93% of referrals were from other oral and maxillofacial surgeons. Over 90% of lesions were located in the oral cavity, and only 6.6% were oropharyngeal primary cancers. Squamous cell carcinoma made up 89% of the lesions, whereas minor salivary gland and metastatic carcinomas comprised the other 11%. At the time of diagnosis, 64.4% of the lesions were early stage (I/II) and 35.6% were late stage (III/IV). Analysis of treatment modalities showed that 87.8% underwent surgery, excluding biopsy, as part of their therapy. Of these, 83.5% were treated with surgery only, whereas the others received both surgery and some form of adjuvant therapy. Five patients were treated with concurrent chemoradiation therapy. Our results suggest that patients referred to an oral and maxillofacial surgery practice for management of head and neck cancer are different from those described in previous reports regarding demographics, social history, site, and stage of disease at diagnosis and treatment. This finding may be explained by the unique referral pattern for oral and maxillofacial surgeons treating head and neck cancer.