Abstract
Objective:
Fine-needle aspiration (FNA) biopsy is the standard diagnostic tool recommended by consensus management guidelines for preoperative evaluation of salivary gland tumors in adults. However, its utility in the pediatric population remains debated due to a paucity of data and inherited challenges of pediatric management (patient cooperation, the need for sedation, and procedural complications).
Methods:
Consecutive series of 92 FNA biopsies of pediatric salivary gland lesions with available procedural data were included for retrospective analysis. Patient demographics, procedural characteristics and complications were assessed.
Results:
Sixty-three patients (68%) tolerated FNA without sedation. Sedation need was significantly associated with younger age, concurrent non-FNA procedure requiring sedation, ultrasound guidance, interventional radiologist as the proceduralist, and radiology suite as the facility setting. The sedation rates for children, early, middle, and late adolescents were 69%, 32%, 12%, and 10%, respectively, with an optimal cutoff point of ≤12 years for age derived from Receiver Operating Characteristic curve analysis. No significant procedural complications were observed. Sedation did not provide significantly better diagnostic yield.
Conclusion:
FNA biopsy of salivary gland tumors is safe, well-tolerated by the pediatric population, and can be effectively performed in an outpatient setting without sedation in most cases. FNA biopsy is a useful tool in the preoperative management of pediatric patients with salivary gland tumors.
Keywords: pediatric, fine-needle aspiration (FNA), salivary gland, compliance, tolerability, cooperation, sedation, anesthesia, complication
INTRODUCTION
Management of pediatric salivary gland tumors is challenging [1–6]. The differential diagnosis of a salivary gland mass in this age group encompasses a wide spectrum of entities that differ significantly from those in the adult population, ranging from developmental and inflammatory lesions to benign and malignant neoplasms [3, 4, 7–9]. Compared to adults, pediatric salivary gland tumors are rare and more likely to be malignant [2, 5, 10–14], particularly when they occur in younger children [13, 15]. While clinical guidelines for work-up and management of salivary gland tumors in the adult population have been well established [16–18], consensus recommendations specific for pediatric patients have not yet been developed.
For the preoperative evaluation of a salivary gland mass in the adults, fine-needle aspiration (FNA) biopsy is universally recommended by the contemporary clinical guidelines as the first-line diagnostic test to assess malignant potential [16–18]. American Society of Clinical Oncology (ASCO) Guidelines further recommend reporting risk of malignancy using the Milan System for Reporting Salivary Gland Cytopathology (MSRSGC) scheme for salivary FNA cytopathology to inform management decisions [17]. However, the utility of FNA biopsy for the management of salivary gland tumors in the pediatric population remains controversial [1, 3, 8, 9, 19–22]. The key challenges and concerns include 1) limited ability to perform FNA in the outpatient setting due to poor procedural compliance and the need to sedate for non-cooperative children, 2) fear of procedural complications, 3) perception of high non-diagnostic rate and low diagnostic accuracy of FNA biopsy in children, and 4) limited high-quality data published in the literature [6, 9, 22–24]. Recently, several retrospective studies independently analyzed pediatric salivary gland tumors with presurgical cytological diagnoses, demonstrating that the sensitivity and specificity of FNA cytopathology in pediatric patients are comparable to those observed in adults [13, 15, 25], and that MSRSGC is a valuable tool for standardization of reporting and preoperative risk stratification [13, 25]. However, patient tolerability, requirement for sedation, and procedural safety of FNA for pediatric salivary gland tumors have not been systematically analyzed.
In this study, we report our institutional experience in FNA biopsy of pediatric salivary gland tumors. We aimed to assess the patient tolerability for FNA, the associated conditions that required sedation, and the overall procedural complications.
MATERIALS AND METHODS
Patient Selection and Data Collection
This study was approved by the institutional review board. Salivary gland FNA performed on patients ≤ 21 years between April 2000 and April 2020 at Vanderbilt University Medical Center were reviewed. For each case, the information collected when available included sex, age, location and size of the lesion, type of FNA (palpation, ultrasound, or CT-guided), proceduralist, procedural setting, status of rapid on-site evaluation, type of anesthesia, concurrent procedure, post-procedure complications, cytologic diagnosis and surgical resection, and clinical follow-up. Only lesions for which an intra-salivary gland location was confirmed by radiologic studies and/or subsequent surgery were included in this cohort. Patients without procedural information including the type of FNA, proceduralist, location, status of anesthesia and outcome were excluded.
FNA Procedure
At the study institution, the FNAs were scheduled by providers (pediatric otolaryngologists or pediatric oncologists). If sedation was considered appropriate by the provider, parents were given a choice of sedation options for the FNA procedure. If sedation was considered unnecessary, the patient received local lidocaine, topical anesthetic, or no anesthesia at all. The FNAs were performed by cytopathologists, radiologists or otolaryngologists with or without image guidance. The settings of FNA procedure included outpatient clinic, radiology suite, and operating room. Patient tolerability was defined by completion of the FNA biopsy procedure based on the clinic notes in medical records. Rapid on-site evaluation (ROSE) was performed in most cases. Air dried and/or alcohol-fixed direct smears were prepared from each pass. The air-dried slides were stained with Diff-Quik stain for ROSE. The alcohol-fixed slides were stained with hematoxylin and eosin stain. The needles were typically rinsed in saline or RPMI medium for flow cytometry analysis, microbiology cultures, or processing as a formalin-fixed cell block, depending on the cytomorphologic findings of the individual cases. Occasional dedicated passes were also obtained for these purposes. FNA diagnoses were retrospectively recategorized according to the MSRSGC. A diagnostic FNA was defined as any of the MSRSGC categories other than category I (nondiagnostic).
Study Group Construction
The patients in this cohort with available procedural information regarding sedation were divided into two groups, sedation (n=29) versus non-sedation (n=63). Patients in the sedation group received anesthesia ranging from minimal sedation to general anesthesia. The specific level of sedation was recorded for all but one patient in this group. Patients in the non-sedation group received either no anesthetic agent, topical anesthetic only, or local lidocaine. Five patients in this group received no sedation according to the medical records, but the exact types of anesthetics were not available for analysis.
Statistical Analysis
A Mann–Whitney U test was used for analysis of patient age and tumor size between sedation and non-sedation groups, whereas a Fisher’s exact test was used for analysis of all other parameters. A Receiver Operating Characteristic (ROC) curve analysis was used to further assess the degree of patient age influenced the decision for sedation. The Youden index was used to derive an optimal cut-off point for age.
RESULTS
One hundred and five cases were identified. Thirteen cases lacking anesthesia data were excluded. The resultant study cohort included 92 patients (41 male) aged from 0 to 21 years (mean, 13.3 years). Among these, 63 patients (68%, non-sedation group) underwent FNA biopsy successfully without sedation. The mean age in the sedation group was significantly younger compared to that in the non-sedation group (8.4 versus 15.6 years, p<0.01). Most lesions involved the parotid gland in both groups (79% and 70%, respectively). The tumors in the sedation group tended to be smaller (1.8 versus 2.8 cm) and have a higher malignancy rate (21% versus 11%) compared to the non-sedation group; however, the differences were not statistically significant. The findings are summarized in Table 1.
Table 1.
Demographic, salivary gland lesion characteristics and final diagnosis in sedation versus non-sedation groups.
| Characteristic | Sedation (n=29) | Non-sedation (n=63) | P value* |
|---|---|---|---|
| Age (mean [range]) (y) | 8.4 (0–19) | 15.6 (0–21) | <0.01 |
| Male: female | 10:19 | 31:32 | 0.26 |
| Anatomic site | |||
| Parotid | 23/29, 79% | 44/63, 70% | 0.45 |
| Submandibular | 6/29, 21% | 18/63, 28% | 0.61 |
| Other | 0/29, 0 | 1/63, 2% (tongue) | 1 |
| Size (mean [range]) (cm) | 1.8 (0.6–6.4) | 2.8 (0.5–7.1) | 0.89 |
| Final diagnosis | Malignant (6/29, 21%) | Malignant (7/63, 11%) | 0.21 |
| Mucoepidermoid carcinoma (n=3) | Secretory carcinoma (n=2) | ||
| Acute myeloid leukemia (n=1) | Metastatic melanoma (n=2) | ||
| Pediatric follicular lymphoma (n=1) | Mucoepidermoid carcinoma (n=1) | ||
| Rhabdomyosarcoma (n=1) | Acinic cell carcinoma (n=1) | ||
| Benign (21/29, 72%) | Rhabdomyosarcoma (n=1) | ||
| Benign cyst (n=8) | Benign (54/63, 86%) | ||
| Benign lymph node (n=4) | Benign lymph node (n=20) | ||
| Sialadenitis (n=4) | Pleomorphic adenoma (n=16) | ||
| Pleomorphic adenoma (n=2) | Benign cyst (n=8) | ||
| Vascular anomaly (n=2) | Vascular anomaly (n=5) | ||
| Sclerosing polycystic adenoma (n=1) | Sialadenitis (n=5) | ||
| No clinical follow-up (n=2) | No clinical follow-up (n=2) |
Mann–Whitney U test was used for analysis of patient age and tumor size, whereas Fisher’s exact test was used for analysis of all other parameters.
Contributing factors to the use of sedation were also investigated (Table 2). Ultrasound guidance, conducted by an interventional radiologist, and radiology suite setting were found to be associated with the sedation group (p < 0.01). However, palpation guidance, performance by a cytopathologist, and outpatient clinic setting were associated with the non-sedation group (p < 0.01). At our institution, most FNAs were palpation-guided (55%, 51/92), followed by ultrasound (42%, 39/92) and CT-guided (2%, 2/92). Overall, 52% (48/92), 41% (38/92) and 7% (6/92) of the FNAs were performed by cytopathologists, interventional radiologists, or otolaryngologists, respectively. Under most circumstances, FNAs performed by cytopathologists took place in an outpatient clinic setting (92%) whereas those by interventional radiologists occurred in the radiology suite (97%). While the modality of FNA procedure, FNA proceduralist type and facility setting were significantly associated with sedation when analyzed individually (Table 2), these three parameters themselves were closely interdependent (Fig 1).
Table 2.
FNA procedural characteristic, type of anesthesia, consecutive procedure and outcome in sedation versus non-sedation groups.
| Characteristic | Sedation (n=29) | Non-sedation (n=63) | P value* |
|---|---|---|---|
| Type of FNA procedure | |||
| Palpation-guided | 5/29, 17% | 46/63, 73% | <0.01 |
| Ultrasound-guided | 22/29, 76% | 17/63, 27% | <0.01 |
| CT-guided | 2/29, 7% | 0/63, 0 | 0.10 |
| FNA performer | |||
| Cytopathologist | 2/29, 7% | 46/63, 73% | <0.01 |
| Interventional radiologist | 24/29, 83% | 14/63, 22% | <0.01 |
| Otolaryngologist | 3/29, 10% | 3/63, 5% | 0.38 |
| FNA procedure location | |||
| Outpatient clinic | 0/29, 0 | 49/63, 78% | <0.01 |
| Radiology suite | 25/29, 86% | 14/63, 22% | <0.01 |
| Operating room | 4/29, 14% | 0/63, 0 | 0.01 |
| Rapid on-site evaluation | 22/29, 76% | 59/63, 94% | 0.03 |
| Adequate | 9/22, 41% | 45/59, 76% | |
| Inadequate | 13/22, 59% | 14/59, 24% | |
| FNA passes (mean [range]) | 2.3 (1–4) | 3.1 (1–7) | <0.01 |
| Diagnostic FNA | 2.2 (1–4) | 3.1 (1–7) | <0.01 |
| Type of anesthesia | General anesthesia (19/29, 66%) | None (38/63, 60%) | |
| Deep sedation (4/29, 14%) | Local lidocaine (15/63, 24%) | ||
| Moderte sedation (4/29, 14%) | Topical anesthetic only (5/63, 8%) | ||
| Minimal sedation (1/29, 3%) | Unspecified type (5/63, 8%) | ||
| Unspecified type (1/29, 3%) | |||
| Consecutive procedure | 12/29, 41% | 0/63, 0 | <0.01 |
| MRI or CT | 9/12, 75% | ||
| Surgical procedure | 3/12, 25%* | ||
| Negative outcome | |||
| Non-diagnostic FNA | 3/29, 10% | 12/63, 19% | 0.38 |
| Post-FNA hematoma | 0/29, 0 | 0/63, 0 |
FNA, fine‐needle aspiration; CT, computed tomography, MRI, magnetic resonance imaging.
The consecutive surgical procedures include transoral resection of lesion (n=1), myringotomy and tympanostomy tube placement (n=1) and drainage of submandibular gland cyst (n=1).
Mann–Whitney U test was used for analysis of FNA passes, whereas Fisher’s exact test was used for analysis of all other parameters.
Figure 1.
Alluvial graph illustrating the distribution of patients according to FNA procedure type (left node), proceduralist (central node), and facility setting (right node). All CT-guided FNAs (n=2) were performed by interventional radiologists. 3% (1/39), 90% (35/39), and 8% (3/39) of ultrasound-guided FNAs (n=39) were performed by otolaryngologists, interventional radiologists, or cytopathologists, respectively. 10% (5/51), 2% (1/51), and 88% (45/51) of palpation-guided FNAs (n=51) were performed by otolaryngologists, interventional radiologists, or cytopathologists, respectively. The FNAs performed by otolaryngologists (n=6) occurred in operation room and outpatient clinic with the same frequency (3/6 for each type of facility). All except one FNA performed by interventional radiologists (37/38) took place in radiology suite. All except two FNAs performed by cytopathologists (46/48) occurred in outpatient clinic.
Rapid on-site evaluation was performed more frequently in the non-sedation group (94% versus 76%, p = 0.03). A slight greater number of FNA passes were performed in the non-sedation group (3.1 versus 2.2) to obtain a diagnostic sample. Concurrent, non-FNA procedures occurred in 12 patients (9 for MRI or CT and 3 for unrelated surgeries), all of whom received continuous sedation for their FNA and non-FNA procedures in the same setting (radiology suite or operating room). No sedation-related side effects, post-FNA hematoma, infection, bleeding, bruising, or any other significant complications were reported. While the non-diagnostic FNA rate was higher in the non-sedation group (19% versus 10%), the difference was not statistically significant (Table 2).
Analysis of the incidence of sedation and non-sedation FNAs by age revealed an inverse correlation between patient age and the frequency for sedation (Fig 2A). An optimal cutoff point of ≤12 years for age was derived by ROC curve analysis with good performance (Area Under the Curve = 0.8350, Fig 2B). When analyzed as different conventional pediatric age groups,[26] a slight majority of the patients aged 0–10 years (69%, 18/26) were found to receive sedation, while only 32% (11/19), 12% (2/17), and 10% (3/30) of the early (aged 11–14 years), middle (aged 15–17 years), and late (aged 18–21 years) adolescents required sedation, respectively (Fig 3). After patient age, the need for a concurrent procedure (or not) was the second major factor determining whether sedation was to be recommended (Fig 3).
Figure 2.
Incidence and distribution of FNA biopsy performed with or without sedation by patient age. (A) Incidence of FNAs by age in sedation and non-sedation groups, showing an association between younger age and the need to sedate. A streamgraph (ThemeRiver) overlays the data. The x-axis represents patient age. The y-dimension represents the number of patients with (pink) or without (light blue) sedation at any given age. (B) Receiver Operating Characteristic curve analysis was used to assess the relationship between patient age and the need for sedation, demonstrating a good correlation (Area Under the Curve = 0.835) with an optimal cutoff point of ≤12 years of age.
Figure 3.
Alluvial graph illustrating the distribution of patients according to conventional pediatric age groups (left node), sedation status (second node), consecutive/concurrent non-FNA procedure status (third node), and procedure type (fourth/right node). The sedation rates in children (aged 0–10 years), early (aged 11–14 years), middle (aged 15–17 years), and late (aged 18–21 years) adolescents were 69% (18/26), 32% (11/19), 12% (2/17), and 10% (3/30), respectively. 41% (12/29) of patients receiving sedation for FNA biopsy had another consecutive/concurrent, sedated procedure. Among those 12 patients with consecutive/concurrent procedures, 1 had CT-guided FNA, 5 had palpation-guided FNA, and 6 had ultrasound-guided FNA. All FNAs without sedation did not have any consecutive/concurrent procedure.
Discussion
As a first-line diagnostic test for preoperative workup of adult salivary gland tumors [16–18], FNA cytopathology currently has gained only limited acceptance in the management of pediatric patients due to a paucity of studies in the literature and its controversial utility [1, 3, 8, 9, 19]. The debate centers on perceived poor tolerability of children, the resultant risk of non-diagnostic FNA biopsy leading to low diagnostic accuracy, the need to sedate, and the concern for procedural complications. The problem of perceived low diagnostic utility has been partially addressed recently by multiple case series demonstrating satisfactory diagnostic accuracy of FNA cytopathology for pediatric salivary gland lesions [13, 15, 25]. In this study, we systematically analyzed the other debated issues that may have limited the utility of FNA, including patient compliance, sedation requirement, and procedural complication.
Our findings indicate that the majority of all pediatric patients (68%) were able to tolerate the procedure well without the need to sedate. When the patients receiving a concurrent procedure that required sedation were excluded from the analysis, the overall patient tolerability rate increased to 79%. The degree of patient tolerability correlated with age, with an expected increase in compliance in older patients. These results support our hypothesis that many pediatric patients, especially older children, can safely and effectively tolerate FNA without sedation [15, 20, 21, 27, 28]. There are several possible reasons for the impression of poor tolerability in children. In the literature, most previous studies appear to have major limitations, providing either a rather general description of institutional experience regarding patient tolerability and sedation requirement, a non-discriminatory compilation of all head and neck tumors without subclassification of salivary gland lesions, or case series with a limited number of pediatric salivary gland tumors. In addition, the practice of FNA cytopathology in pediatric patients with salivary gland tumors is highly variable among different institutions regionally, nationally, and internationally. For example, in the series by Ronchi et al [15] and Ramadan et al [28], all of the salivary gland FNAs were performed without sedation [15]. However, in a series by Orvidas et al, none of the 118 children with parotid masses received FNA preoperatively [9]. Our study provided a systematic analysis of FNA biopsy procedure tolerability by children of different age groups using a relatively large cohort focusing specifically on salivary gland lesions.
At our institution, the decision for recommendation of a pediatric patient for FNA to assess a salivary gland mass prior to surgery is made by a pediatric otolaryngologist or a pediatric oncologist. Whether sedation is needed or not is influenced by multiple factors. If no additional major procedure is planned, the lesion is easily assessable by palpation, and the provider determines (with parental consent) that the FNA procedure can be well tolerated by a child without sedation, then the FNA is scheduled to be performed by an experienced cytopathologist at an outpatient clinic, often during patient’s same visit to the primary provider. In this setting, all FNAs were palpation-guided and most (94%) received rapid on-site evaluation. 60% of the patients did not require any topical or local anesthesia, while 24% received local lidocaine. The age of 12 years or younger as an optimal cutoff for sedation was derived from the analysis of our institutional data, although as many as 53% (10/19) of patients aged 9–12 years did tolerate the FNA well without sedation. This is consistent with the experience by Amedee et al [21] that children older than 7 years of age are fairly cooperative and amenable to FNA without the need to sedate. On the other hand, for patients receiving an additional sedated procedure (performed immediately preceding or after), an FNA is scheduled in the same setting of the non-FNA procedure (operating room or radiology suite) with sedation, regardless of the age. This can be performed by either a cytopathologist if the lesion is assessable by palpation, or by an interventional radiologist if the lesion is small, deep-seated, complex, and requires image-guidance. If the primary provider determines that successful biopsy of a lesion is challenging and requires image-guidance, then the FNA is scheduled to be performed by an interventional radiologist at the radiology suite who further assesses whether sedation is necessary.
Although procedural complication is a major concern for FNA in children, we observed no significant adverse outcome except for local discomfort from needle stick, regardless of the sedation status. Our observation is in keeping with the previous studies which reported no complication for all patients with salivary gland lesions in their series [15, 28, 29] and the review by Amedee et al [21] that virtually no contraindications and only minimal complications were found for children with palpable head and neck masses.
The rate of non-diagnostic FNA was lower in the sedation group compared to the non-sedation one (10% versus 19%), although statistical significance was not observed (p = 0.38). All three non-diagnostic cases with sedation were performed by interventional radiologists. Two were ultrasound-guided and one was palpation-guided. The higher percentage of image-guided FNAs in the sedation group likely contributed to the lower rate of non-diagnostic FNAs, as ultrasound-guided FNAs have been shown to have higher diagnostic performance compared to palpation-guided FNAs [30].
In conclusion, our data demonstrate FNA as a safe and well-tolerated diagnostic tool for the initial evaluation of salivary gland lesions in pediatric patients. It can be effectively performed in an outpatient setting without the need to sedate, particularly for children older than 12 years of age. Thus, our study provides additional evidence supporting the utility of FNA biopsy in the preoperative management of pediatric patients with salivary gland tumors. Further studies are needed for removing the roadblocks to the establishment of management guidelines specific for the pediatric population.
Funding Sources
This study is not supported by any funding or grants.
Footnotes
Statement of Ethics
This study protocol was reviewed and approved by the Institutional Review Board for human research subjects at Vanderbilt University, approval number 191169.
Conflict of Interest Statement
None of the authors have any conflicts of interest to declare.
Data Availability Statement
All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.
References
- 1.Aro K, Leivo I, Makitie A. Management of salivary gland malignancies in the pediatric population. Curr Opin Otolaryngol Head Neck Surg. 2014;22(2):116–20. [DOI] [PubMed] [Google Scholar]
- 2.Yoshida EJ, Garcia J, Eisele DW, Chen AM. Salivary gland malignancies in children. Int J Pediatr Otorhinolaryngol. 2014;78(2):174–8. [DOI] [PubMed] [Google Scholar]
- 3.Lennon P, Silvera VM, Perez-Atayde A, Cunningham MJ, Rahbar R. Disorders and tumors of the salivary glands in children. Otolaryngol Clin North Am. 2015;48(1):153–73. [DOI] [PubMed] [Google Scholar]
- 4.Luna MA, Batsakis JG, el-Naggar AK. Salivary gland tumors in children. Ann Otol Rhinol Laryngol. 1991;100(10):869–71. [DOI] [PubMed] [Google Scholar]
- 5.Ord RA, Carlson ER. Pediatric Salivary Gland Malignancies. Oral Maxillofac Surg Clin North Am. 2016;28(1):83–9. [DOI] [PubMed] [Google Scholar]
- 6.Jaryszak EM, Shah RK, Bauman NM, Howell RJ, Rossi CT, Preciado DA. Unexpected pathologies in pediatric parotid lesions: management paradigms revisited. Int J Pediatr Otorhinolaryngol. 2011;75(4):558–63. [DOI] [PubMed] [Google Scholar]
- 7.Ellies M, Laskawi R. Diseases of the salivary glands in infants and adolescents. Head Face Med. 2010;6:1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Bentz BG, Hughes CA, Ludemann JP, Maddalozzo J. Masses of the salivary gland region in children. Arch Otolaryngol Head Neck Surg. 2000;126(12):1435–9. [DOI] [PubMed] [Google Scholar]
- 9.Orvidas LJ, Kasperbauer JL, Lewis JE, Olsen KD, Lesnick TG. Pediatric parotid masses. Arch Otolaryngol Head Neck Surg. 2000;126(2):177–84. [DOI] [PubMed] [Google Scholar]
- 10.Carlson ER, Schlieve T. Salivary Gland Malignancies. Oral Maxillofac Surg Clin North Am. 2019;31(1):125–44. [DOI] [PubMed] [Google Scholar]
- 11.Eveson JW, Cawson RA. Salivary gland tumours. A review of 2410 cases with particular reference to histological types, site, age and sex distribution. J Pathol. 1985;146(1):51–8. [DOI] [PubMed] [Google Scholar]
- 12.Wang XD, Meng LJ, Hou TT, Huang SH. Tumours of the salivary glands in northeastern China: a retrospective study of 2508 patients. Br J Oral Maxillofac Surg. 2015;53(2):132–7. [DOI] [PubMed] [Google Scholar]
- 13.Wang H, Weiss VL, Borinstein SC, Ely K, Johnson J, Coogan A, et al. Application of the Milan System for Reporting Pediatric Salivary Gland Cytopathology: Analysis of histologic follow-up, risk of malignancy, and diagnostic accuracy. Cancer Cytopathol. 2021:129(7);555–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Pusztaszeri M, Baloch Z, Vielh P, Faquin WC. Application of the Milan system for reporting risk stratification in salivary gland cytopathology. Cancer Cytopathol. 2018;126(1):69–70. [DOI] [PubMed] [Google Scholar]
- 15.Ronchi A, Montella M, Zito Marino F, Panarese I, Pagliuca F, Colella G, et al. Diagnostic accuracy of FNA cytology for diagnosis of salivary gland tumors in pediatric patients. Cancer Cytopathol. 2019;127(8):529–38. [DOI] [PubMed] [Google Scholar]
- 16.Colevas AD, Yom SS, Pfister DG, Spencer S, Adelstein D, Adkins D, et al. NCCN Guidelines Insights: Head and Neck Cancers, Version 1.2018. J Natl Compr Canc Netw. 2018;16(5):479–90. [DOI] [PubMed] [Google Scholar]
- 17.Geiger JL, Ismaila N, Beadle B, Caudell JJ, Chau N, Deschler D, et al. Management of Salivary Gland Malignancy: ASCO Guideline. J Clin Oncol. 2021;39(17):1909–41. [DOI] [PubMed] [Google Scholar]
- 18.Sood S, McGurk M, Vaz F. Management of Salivary Gland Tumours: United Kingdom National Multidisciplinary Guidelines. J Laryngol Otol. 2016;130(S2):S142–S9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Mathew S, Ali SZ. Parotid fine-needle aspiration: a cytologic study of pediatric lesions. Diagn Cytopathol. 1997;17(1):8–13. [DOI] [PubMed] [Google Scholar]
- 20.Alam K, Khan R, Jain A, Maheshwari V, Agrawal S, Chana RS, et al. The value of fine-needle aspiration cytology in the evaluation of pediatric head and neck tumors. Int J Pediatr Otorhinolaryngol. 2009;73(7):923–7. [DOI] [PubMed] [Google Scholar]
- 21.Amedee RG, Dhurandhar NR. Fine-needle aspiration biopsy. Laryngoscope. 2001;111(9):1551–7. [DOI] [PubMed] [Google Scholar]
- 22.Anne S, Teot LA, Mandell DL. Fine needle aspiration biopsy: role in diagnosis of pediatric head and neck masses. Int J Pediatr Otorhinolaryngol. 2008;72(10):1547–53. [DOI] [PubMed] [Google Scholar]
- 23.Daniel SJ, Al-Sebeih K, Al-Ghamdi SA, Manoukian JJ. Surgical management of nonmalignant parotid masses in the pediatric population: the Montreal Children’s Hospital’s experience. J Otolaryngol. 2003;32(1):51–4. [DOI] [PubMed] [Google Scholar]
- 24.Ethunandan M, Ethunandan A, Macpherson D, Conroy B, Pratt C. Parotid neoplasms in children: experience of diagnosis and management in a district general hospital. Int J Oral Maxillofac Surg. 2003;32(4):373–7. [DOI] [PubMed] [Google Scholar]
- 25.Satturwar SP, Fuller MY, Monaco SE. Is Milan for kids?: The Milan System for Reporting Salivary Gland Cytology in pediatric patients at an academic children’s hospital with cytologic-histologic correlation. Cancer Cytopathol. 2021;129(11)884–92. [DOI] [PubMed] [Google Scholar]
- 26.Hardin AP, Hackell JM, Committee On P, Ambulatory M. Age Limit of Pediatrics. Pediatrics. 2017;140(3). [DOI] [PubMed] [Google Scholar]
- 27.Buchino JJ, Lee HK. Specimen collection and preparation in fine-needle aspirations in children. Am J Clin Pathol. 1998;109(4 Suppl 1):S4–8. [PubMed] [Google Scholar]
- 28.Ramadan HH, Wax MK, Boyd CB. Fine-needle aspiration of head and neck masses in children. Am J Otolaryngol. 1997;18(6):400–4. [DOI] [PubMed] [Google Scholar]
- 29.Tunkel DE, Baroody FM, Sherman ME. Fine-needle aspiration biopsy of cervicofacial masses in children. Arch Otolaryngol Head Neck Surg. 1995;121(5):533–6. [DOI] [PubMed] [Google Scholar]
- 30.Conrad R, Yang SE, Chang S, Bhasin M, Sullivan PS, Moatamed NA, et al. Comparison of Cytopathologist-Performed Ultrasound-Guided Fine-Needle Aspiration With Cytopathologist-Performed Palpation-Guided Fine-Needle Aspiration: A Single Institutional Experience. Arch Pathol Lab Med. 2018;142(10):1260–7. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.