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Adenoid cystic carcinoma is a relatively uncommon malignancy constituting approximately 1% of head and neck malignancies and approximately 10% of salivary gland tumors. It is the most common malignant tumor of the minor salivary glands and can occur throughout the head and neck, including in the major and minor salivary glands, nasal cavities and lacrimal glands. It is characterized by an indolent growth pattern with lymph node metastasis being uncommon, occurring only in approximately 10–15% of cases. Yet, despite this indolent biological behavior, it is classified as a high grade malignancy, primarily due to its propensity to recur locally despite clear surgical margins. Surgery is the mainstay of treatment, with complete excision especially of early-stage tumors leading to an excellent prognosis. Schroeder et al. looking at various parotid gland malignancies in a retrospective trial, reported a 5 year disease free survival of 86%. Patients with more advanced stage disease had a poorer prognosis. Risk factors for recurrence include bone invasion and positive margins as well as T3 or T4 disease. Distant metastasis, predominantly to the lungs, sometimes decades following excision of the primary, is very common and is often the cause of death. Early perineural invasion, one of the defining characteristics of this tumor, is thought to be responsible for spread outside grossly and microscopically visible margins. Because of its low incidence, randomized prospective studies have been difficult to perform. Importantly, in contrast to most head and neck malignancies, short-term survival does not correlate with long-term survival as late recurrences are the rule rather than exception. While surgery for a resectable primary tumor, followed by radiation therapy is the current accepted standard of care, no prospective data exist to objectively assess the contribution of adjuvant radiotherapy to long-term survival. Data supporting the use of adjuvant radiation are limited to retrospective reviews showing improved local control. Even less evidence exists to support primary or adjuvant chemotherapy although the currently enrolling NRG 1008 trial, ‘‘A Randomized Phase II/III Study of Adjuvant Concurrent Radiation and Chemotherapy versus Radiation Alone in Resected High-Risk Malignant Salivary Gland Tumors’’ is designed to shed light on this question. In the absence of prospective data, studies of long-term survival have been limited to population-based database investigations, such as the one by Shen et al published in this issue of Annals of Surgical Oncology. The authors performed competing risks analysis and constructed a nomogram of disease specific survival of adenoid cystic carcinoma of the head and neck. Such analysis is particularly important given long term survival and late recurrences that increase the chances of death from unrelated causes. Several previous studies examining survival of adenoid cystic carcinoma have been completed in both the US and internationally. A study by Ellington et al. similarly used a Surveillance, Epidemiology, and End Results (SEER) database but focused on an earlier time period. In that study, 5-, 10and 15 year overall survival was 90.3, 79.9, and 69.2%, respectively, with female sex, absence of distant disease, married status, oral primary and surgical treatment being associated with improved survival. A large European population study of 2611 patients similarly found female sex, younger age and oral cavity primary subsite to be predictive of improved survival, i.e. 78 and 65% at 5 and 10 years, respectively. A smaller Society of Surgical Oncology 2017

Model to Predict Cause-Specific Mortality in Patients with Head and Neck Adenoid Cystic Carcinoma: A Competing Risk Analysis