SALIVARY GLAND TUMORS - PowerPoint Presentation

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SALIVARY GLAND TUMORS

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Salivary tumors 7% of head and neck tumors

Parotid tumors >submandibular > lingual

Equal incidence between sexes

Risk Factors: nutritional deficiency, exposure to ionizing radiation, UV exposure, genetic predisposition, EBV

Epidemiology

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Benign Tumors

Pleomorphic

Adenomas

Mnomorphic Adenoma( Warthin’s tumor

Malignant Tumors

Parotid – mucopidermoid Ca most common –

Submandibular and minor salivary –

adenoid cystic most common. Adenocarcinoma

Pathology

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Parotid 80% benign

Submandibular 50% malignant

Sublingual majority (65-88%) are malignant

Minor…… 90% malignant

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Tumors of minor salivary Glands

Benign tumours present as painless slow growing swellings, overlying ulceration is rare.

Malignant tumours have firmer consistency and have ulceration at later stage

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Tumors of minor salivary Glands

MSG tumours are rare but 90% are malignant

Common sites include

Upper lip

Palate

Retromolar

regions

Rare sites are nose/PNS/Pharynx

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Tumors of minor salivary Glands

Benign tumors of the lip…. Excision..primary closure

Benign tumors of palate < 1cm in size are removed by excisional biopsy… 2ndry healing

When size larger than 1 cm prior incisional biopsy is done

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Incisional biopsy

Malignant tumors of palate are managed by excision which may involve low-level or total maxillectomy and immediate reconstruction with vascularized free flap or prosthetic obturators.

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Disorders of sublingual salivary Glands

Tumours are rare

>80% are malignant

Never do incisional biopsy

Surgery

Small and localized can be resected without submandibular glandGenerally requires resection of submandibular gland as well..

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Uncommon, slow growing, painless

Only 50% are benign

Even malignant tumours can be slow growing

Pain is not a reliable feature

Investigations:

CT/MRIFNAC

No open biopsy

Tumors of Submandibular Salivary Glands

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Surgery

Small tumor – gland excision

ECE –En bloc resection with extended supraomohyoid neck dissection

Sub mandibular gland tumors

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Indications

Close surgical margins (deep lobe parotid tumors, facial nerve sparing)

Microscopically positive margin

High grade including adenoid cystic

Involvement of skin, bone, nerve (gross or extensive

perineural invasion), tumor extension beyond capsule with

periglandular

and soft tissue invasionLN spreadLarge tumors requiring radical resectionTumor spillageRecurrence

Postoperative Radiation

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– Surgically

unresectable tumors

EBRT with photon and or electrons with conventional or altered fractionation

Brachytherapy ± EBRT

Neutron therapy

Radiation only

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Parotid Gland

The parotid gland represents the largest salivary gland

The following lists the boundaries of the parotid compartment:

•Superior border – Zygoma

•Posterior border – External Auditory Canal

•Inferior border – Styloid Process, & its musculature, Internal Carotid Artery, Jugular Veins

•Anterior border – a diagonal line drawn from the Zygomatic root to the EAC

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Parotid Gland……

Stensen’s

duct arises from the anterior border of the Parotid

It runs superficial to the

masseter muscle, then turns medially 90 degrees to pierce the Buccinator

muscle at the level of the second maxillary molar where it opens onto the oral cavity.

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Parotid Gland……

80% of the gland overlies the

Masseter

and mandible. The remaining 20% of the gland (the

retromandibular

portionThis portion of the gland lies in the Prestyloid

Compartment of the

Parapharyngeal space

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Branches of facial nerve

Terminal branches of ECARetromandibular

vein

Intra parotid lymph node

Structure with in parotid gland

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Parotid Gland……

Cranial Nerve VII divides it into 2 surgical zones (the superficial and deep lobes).

After exiting the foramen, it turns laterally to enter the gland at its posterior margin.

The nerve then branches at the

Pes

Anserinus

(goose’s foot) approximately 1.3 cm from the stylomastoid foramen. The nerve then gives rise to 2 divisions:1)Temporofacial (upper)

2)

Cervicofacial

(lower)

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Parotid Gland……

Followed by 5 terminal branches:

1)Temporal

2)Zygomatic

3)Buccal

4)Marginal Mandibular

5)Cervical

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Common causes of parotid swelling:

viral infection. Mumps

Bacterial

sialadenitis in dehydrated elderly patientsRecurrent

parotitis

of childhoodHIV associatedObstructive parotitis

: causes swelling at meal time

Disorders of parotid Glands

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Most Common is

pleomorphic

adenoma (80-90%)

Low grade Tumors like acinic cell carcinoma are not distinguishable from benign

High grade Tumours grow rapidly, are often painful and have nodal metastasis

CT/MRI are usefulFNAC better than open biopsyTx

should be excised & not enucleated

Parotid Tumours

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Pleomorphic

adenoma (benign mixed tumor).

Warthin

’s

tumor (papillary cyst adenoma

lypmhomatosum).Monomorphic adenoma

a. Basal cell adenoma

b. Canalicular adenomas c. Oncocytoma d. Myoepitheliomas

4. Granular cell tumor

5.

Hemangioma

What are the most common benign tumor of the parotid?

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Mucoepidermoid

carcinoma

–

40%

It can high, intermediate, and low-grade base on the clinical behavior and the tumor differentiation which is related to the percentage of

mucinous to epidermoid cell.

2. Adenoid cystic carcinoma

– 10% Adenoid cystic carcinoma are unique among the salivary gland tumors because of their indolent and protracted clinical course. Characterized by preneural

spread including skip lesions.

The disease thus specific survival continuous to declined for more than 20 years after initial treatment.

What are the most common malignant neoplasm of the parotid gland?

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High-grade: aggressive behavior, local invasion, and lymph node metastasis.

- high grade

mucoepidermoid

carcinoma

- adenoid cystic carcinoma

- carcinoma ex

phelomorphic

adenoma - adenocarcinoma - aquamous cell carcinoma

- undifferentiated carcinoma

The malignant parotid tumor can be classified into:

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2. Low-grade malignancy

- low grade

mucoepidermoid

carcinoma - pholymorphous low grade

adenocarcinoma

- acinic cell carcinoma - low grade adenocarcinoma

- basal cell carcinoma

3. Intermediate grade - intermediate grade mucoepidermoid carcinoma - intermediate grade adenocarcinoma - oncocytic carcinoma

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Management

Superficial parotidectomy most common procedure

Radical parotidectomy is performed for patients clear histological evidence of high grade malignancy

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Evaluation of patients with a parotid mass

History

Important points in the history:

- Parotid mass (duration, rate of the growth,

presence of pain)

- Facial paralysis

- Cervical lymphadenopathies - Eyes and joints symptoms - History of exposure to radiation

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2.

Examination

- Size of the mass

- Skin fixation

- Cervical adenopathies

- Facial nerve functions

3.

Investigation C.T. and MRI are both effective modalities for imaging the size, the local, and the regional extension of the primary tumor and the neck metastasis. C.T. saliography – it replaced now by high-resolution contrasted C.T. and MRI.

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4.

FNAB

- The accuracy is around 90% depend on the

techniques of aspirate and the

cytopathologist.

5. Superficial parotidectomy is considered as a diagnostic and therapeutic for most benign tumors.

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The post-operative complications:

Skin flap necrosis

Hematoma

Salivary fistula and sialoseles

–

it presents as an opening in the suture line below the lobule of the ear.

Facial nerve paralysis

– which could be: a. Temporarily: 5 – 10% of the patients. b. Permanent: less than 2% of the cases.

5. Numbness of the ear due to injury of great auricular nerve.

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6. Xerostomia not common in the superficial parotidectomy (30% of salivary producing tissue).

5. Frey

’

s syndrome (Gustatory sweating syndrome)

Incidence in 50% of the patients.

Etiology: post-operative growth of the interrupted preganglionic parasympathetic nerve branches to the parotid into the more superficial sweat glands. The diagnosis is usually made from the history but can be confirmed by the starch-iodine test.

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Paint the affected skin with iodine, dust the skin with the starch, feed the patient. The appearance of bluish discoloration of the overlying skin due to reaction of starch and iodine in the presence of moisture (sweat.

What is starch-iodine test?

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How do you treat Frey

’

s syndrome?

Parasymphatholytic

creams such as

glycopyrrolate

lotion

Apply anti-perspirant to avoid sweating.

Jacobsen

’

s

neurectomy

via

tympanotomy

approach.

Elevating skin flap and placing tissue such as fascia, dermis, or creating SCM muscle flap.

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Facial nerve paralysis

In parotid malignancy

Patient with clinically pre-op facial nerve paralysis. What to do

?

Intra-operative resection of the involved part of the facial nerve and primary grafting using greater auricular nerve or

sural

nerve. Post-operative radiotherapy (high-grade)

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b.

Patient with a normal facial function but intra-operative involvement of the facial nerve. What to do?

Careful dissection of the tumor of the facial nerve without

sacrifying

the facial nerve and followed-up with radiotherapy treatment.

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During an operation on the parotid, where do you find the facial nerve?

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Tragal

cartilage (pointer)

–

always point to the facial nerve.

The facial nerve is 1 cm. inferior and 1 cm. medial to the pointer.

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2.

Tympanomastoid

fissure

– FN is 4 mm inferior to the

tympano

mastoid fissure as it exit from the stylo mastoid foramen.

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3. Posterior belly of

digastric

muscle. The facial nerve is superior to the upper border of the belly of the

digastric muscle.

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4. Retrograde inferior approach to the facial nerve.

The lower branch of the facial nerve invariably can be found immediately external to the posterior facial vein as it exits the lower pole of the parotid gland.

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5. Retrograde anterior approach.

The parotid duct is constant imposition as it goes horizontally across the border of

masseter

muscle. It

’

s always accompanied by a branch of buccal

or

zygomatic branch within 1 cm. of the duct.

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Does the grading make difference in management of the parotid malignancy?

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Group 1: T1 and T2NO low-grade malignancy

Treatment is excision of the tumor with cuff of a normal tissue.

Facial nerve is preserved.

Regional lymph node evaluated at the time of surgery.

No post-op radio therapy unless the resection margin is not clear.

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Group 2: T1 and T2NO high-grade malignancy

Treatment is total parotidectomy with excision of the first echolon node (digastric and submandibular nodes).

Facial nerve involvement:

a. patient with facial paralysis pre-operatively.

Resection of the facial nerve with primary grafting.

b. patient with normal facial function pre-op.

Resect the tumor of the facial and post-operative

wide field radiation.

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Group 3: T3NO or any N+ high-grade or

recurrent cancer.

Treatment is total parotidectomy

Modified radical neck dissection

Post-operative wide field radiotherapy

Facial nerve as in group 2

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Group 4: include all T4 tumor

Treatment is radical parotidectomy with modified radical neck dissection and resection of masseter muscle, part of the mandible or mastoid or ear canal as required.

Resection of the facial nerve with the tumor and primary grafting.

Followed by wide field post-operative radiotheray.

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Points to remember in parotid surgery:

Pre-op evaluation: general condition of the patient, hemoglobin, LFT and U & E

’

s

2. Consenting patients for possible facial weakness.

3. Operating in bloodless field by:

a. hypotensive technique

b. elevation of the head of the bed

c. delicate tissue handling

d. proper hemostasis

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4. Using facial nerve monitoring during operation and at the end of operation.

5. Exposure of the eye and the operative side of the face.

6. Modified blair incision.

7. Landmark for the facial nerve.

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Indications of neck dissection

Neck dissection is a recommended treatment of the neck for the malignant salivary gland tumor, when?

2. If there is a clinically cervical adenopathies (15%).

Parotid tumor bigger than 4cm, why?

(the risk of occult metastasis over 20%).

3. High grade malignancy, why?

(the risk of occult metastasis over 25%).

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Indications of post-operative radiotherapy

High-grade tumor

Gross or microscopic residual disease

Tumor involving or close to the facial nerve

Recurrent disease

Documented lymph node metastasis

Extraparotid extension

Deep lobe cancersAll T3 and T4 cancers

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Sjogren Syndrome

Autoimmune condition causing progressive degeneration of salivary and lachrymal glands

The oral aspects of primary Sjogren's syndrome consist of mucosal atrophy (80% to 95%), salivary gland enlargement approximately 30 %),

The oral manifestations may include xerostomia with or without salivary gland enlargement, candidiasis, dental caries and taste dysfunction.

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Investigations

Sialometry

Sialography

Scintigraphy

a radioactive tracer is given by vein that is subsequently taken up by the salivary glands and gradually eliminated within the salivary fluid Sialochemistry

Ultrasonogram Labial or minor salivary gland biopsy

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Symptomatic

From the systemic drug treatment standpoint, immunosuppressive therapy in the form of corticosteroids or

cytotoxic

drugs have proven effective, in particular when symptoms are severe. Cosmetic. Superficial

parotidictomy

Management

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Questions?

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