ppt on salivary gland tumors with anatomy.pptx

salivary gland tumors and its management

1. Salivary Gland Tumors 1

2. ANATOMY AND LYMPHATIC DRAINAGE

3. Salivary Glands The Major Salivary Glands Parotid Submandibular Sublingual The Minor Salivary Glands 3

4. Applied Anatomy – Parotid Gland There is no true anatomic separation, the parotid gland is arbitrarily divided into “superficial” and “deep” lobes by the plane of the facial nerve. 4

5. Extensive lymphatic capillary plexus Numerous intraglandular LN in the superficial lobe Lymphatics drain from – Lateral areas on the face & Frontal region of the scalp. Associated with the gland are parotid nodes, drain downward along the retromandibular vein to empty into – Superficial lymphatics , Nodes along the sternocleidomastoid muscle & Upper nodes of the deep cervical chain. 5

6. 6 There are numerous lymph nodes located within, and adjacent to, the capsule of the parotid gland that serve as the first echelon of nodal drainage for the temporal scalp, portions of the cheek, the pinna, and the external auditory canal. For this reason, the parotid gland may harbor metastatic cutaneous malignancy from these sites E f f e re n t l y m phati c s fr o m the g la n d co mm un i c a te w i t h l y m ph nodes of the upper and middle deep jugular chain. Lymphatics Drainage

7. Positive neck nodes (percent) at first presentation according to site and level (I–V). 7 Lymphnodal spread

8. WHO CLASSIFICATIONS OF SGTs Adenomas Pleomorphic adenoma Warthin’s tumor (adenolymphoma) Myoepithelioma ( m y oe p i t heli a l adenoma) Basal cell adenoma Oncocytoma (Oncocytic adenoma) Canalicular adenoma Sebaceous adenoma Ductal Papilloma Inverted ductal papilloma Intraductal papilloma Sialadenoma papilliferum Cystadenoma P a pill ary c y s tadenoma Mucinous cystadenoma Carcinomas Mucoepidermoid carcinoma Adenoid cystic carcinoma Acinic cell carcinoma Polymorphous low-grade adenocarcinoma E p it h eli a l - m y o e p it h elial carcinoma Basal cell adenocarcinoma Sebaceous carcinoma Papillary cystadenocarcinoma Mucinous adenocarcinoma Oncocytic carcinoma Salivary duct carcinoma Adenocarcinoma Malignant myoepithelioma Squamous cell carcinoma Small cell carcinoma Undifferentiated carcinoma Miscellaneous Nonepithelial tumors Malignant lymphomas Secondary tumors Unclassified tumors Tumor-like lesions Sialadenosis Oncocytosis Necrotizing s i a lome t a p l a s i a (salivary gland infarction) Benign lymphoepithelial lesion Salivary gland cysts Chronic sclerosing sialedenitis of submandibular gland (Kuttner tumor) Cystic lymphoid hyperplasia in patients with acquired immunodeficiency syndrome

9. Carcinomas - Histologic Types Mucoepidermoid Carcinoma 34% Adenoid Cystic Carcinoma 22% Adenocarcinoma 18% Carcinoma ex pleomorphic adenoma 13% Acinic cell carcinoma 7% Squamous cell carcinoma 4%

10. 11 Mucoepidermoid Carcinoma Most common salivary gland malignancy 5-9% of salivary neoplasms Parotid 70-80% of cases (most common in parotid) 3 rd - 8 th decades, peak in 5 th decade F>M Caucasian > African American Presentation Low-grade: slow growing, painless mass High-grade: rapidly enlarging, +/- pain Stained +ve by muscarmine.

11. Gross pathology Well-circumscribed to partially encapsulated to unencapsulated Solid tumor with cystic spaces Mucoepidermoid Carcinoma 12

12. MECs contain two major elements: Epidermoid and Mucinous components 13 Mucoepidermoid Carcinoma

13. 14 Adenoid Cystic Carcinoma Overall 2 nd most common malignancy Most common in submandibular, sublingual and minor salivary glands M = F 5 th decade Presentation Asymptomatic enlarging mass Pain, paresthesias, facial weakness/paralysis

14. Gross pathology Well-circumscribed Solid, rarely with cystic spaces Infiltrative Unique features Locally aggressive, with local recurrences often after many years. Perineural infiltration Asymptomatic large pulmonary mets Adenoid Cystic Carcinoma 15

15. 3 basic growth patterns : Tubular – grade 1 Cribriform – grade 2 Solid – grade 3 16 Adenoid Cystic Carcinoma

16. CLINICAL FEATURES

17. 18 SGTs - Clinical Presentation LOCAL “Pai n le s s , r a p i d l y e n la r g i n g mas s (present for y e a r s) before a sud d en change in its growth pattern” Painless submucosal mass – Minor salivary gland tumour Pain (10% to 20%) - malignant disease. REGIONAL Pain - involvement of deeper structures (masseter, temporal, and pterygoid ms). Mucosal ulceration in the palate , lips, or buccal mucosa Malignant tumours - median duration of clinical symptoms is shorter (3 to 6 months) in comparison to benign (10 years)

18. 19 SGTs - Clinical Presentation T umours o f par o tid m a y in v ol v e the b ase o f s k ull and intractable pain and paralysis of various cranial nerves. 1/3rd of parotid cancers may have facial nerve involvement cau s e Deep lobe parotid – tonsillar and palatal bulge Sublingual – ulcerated mass in floor of mouth

19. 20 Minor Salivary Gland tumours S/S associated with tumours of minor salivary glands vary because of their diverse locations. Most are intraoral, and a painless lump is the most common presenting symptom. Tumours of nasal cavity or sinuses, facial pain is most common presenting symptom , followed by nasal obstruction. Laryngeal primary tumours most frequently cause hoarseness or voice change. SGTs - Clinical Presentation

20. Malignant salivary gland tumour Rapid growth rate Pain Facial nerve palsy Childhood occurrence Skin involvement and Cervical adenopathy SGTs - Clinical Presentation 21

21. DIAGNOSTIC WORK-UP

22. 23 Diagnostic Work-Up Major Salivary Glands History Physical examination with particular to signs of local fixation or regional adenopathy. Laboratory Investigation Radiology for locoregional assessment CT scans - evaluating the extent of lesions involving the parotid gland. - Temporal bone or mandibular bone invasion/destruction MRI - superior to other modalities Metastatic workup – CXR ,USG abdomen, Bone scan , ?PET scan

23. Diagnostic Work-Up Major Salivary Glands MRI 24

24. 25

25. 26 Histopathological Diagnosis FNAC A reliable procedure. The sensitivity for malignancy varies between 80% - 90%; the specificity is > 90%. False-negative findings may be seen as result of lack of representative material or a cyst(Ultrasound fine-needle aspiration is advised) Negative predictive value for malignancy 70% to 75% Low negative predictive value of FNAC will be improved if MRI and fine-needle aspiration are combined. Other options – Trucut biopsy (metastatic ds with inconclusive FNAC) Superficial/Total Parotidectomy (Grand biopsy) submandibular gland excision

26. Minor Salivary gland tumour MRI/CT – none has been validated FNAC – no role Especially if malignancy is suspected Polymorphism is most pronounced with malignant tumours Biopsy – Ideal tissue proof Unplanned incisional biopsy avoided Excisional biopsy /trucut

27. S T A GING

28. TREATMENT MODALITIES Surgery Radiotherapy C h emotherapy 29

29. Treatment Outline Benign & Low grade tumours – Typically treated with surgery alone High-grade carcinomas and those with positive margins or other high-risk features - – Usually treated with surgery and adjuvant radiation therapy (RT) Unresectable tumors – May be treated with RT alone or RT in combination with chemotherapy

30. Surgery 31 Surgical resection is the principal form of treatment for both benign and malignant salivary tumors Complete surgical resection is the cornerstone of treatment when this can be achieved with negative surgical margins Aggressive surgery does not improve disease-free survival. Facial nerve grafting with the greater auricular or sural nerve graft decreases the incidence of facial palsy postoperatively, especially if branches and not the main trunk are involved Adjuvant postoperative radiotherapy has no negative effect on facial nerve function

31. Surgical Options In Parotid Surgery Local Excision vs. Enucleation Superficial Conservative parotidectomy Superficial parotidectomy (VII sacrificed) Total parotidectomy Extended parotidectomy - Mandible, masseter, T-bone, etc., Neck dissection

32. Options In Parotid Surgery Local Excision vs. Enucleation Enucleation, has no role in surgical management of salivary neoplasms Pleomorphic adenoma has a pseudocapsule, so there is almost certainly residual tumor after simple excision, resulting in frequent relapses It is important to avoid enucleation and excision biopsy because it greatly increases the likelihood of recurrence (up to 80%) and nerve damage

33. 34 Options In Parotid Surgery Superficial Conservative Parotidectomy I t i s the “t r ea t m en t o f choic e ” for tumors i n t he supe r f i c i al lobe, which are not involving the facial nerve. Implies complete removal of the parotid gland superficial to the plane of the facial nerve It is the minimum standard surgical procedure. Less extensive than a superficial parotidectomy Does not fully dissect the facial nerve

34. 35 Options In Parotid Surgery Total Conservative Parotidectomy (Facial N sparing) Implies excision of entire parotid gland (superficial and deep lobes), while preserving the facial nerve Done for tumors involving the deep lobe with – Intact facial nerve functions, High-grade malignant tumors with a high risk for metastasis, A n y pa r otid m alig n a n c y w ith an indic a tion o f m e tas t a s is cervical lymph nodes, t o i n tragl a ndular or Any primary malignancy originating within the deep lobe itself, Positive margin (base) after superficial parotidectomy

35. 36 Total Parotidectomy with the Excision of Facial nerve Indications as above, when the nerve is involved by the tumor Options In Parotid Surgery

36. 37 Radical/Extended Parotidectomy When tumour is extending beyond the parotid gland Implies excision of structures in addition to parotid gland and facial nerve. Done when tumor involves: – Skin, Infra-temporal fossa, Masseter, Mandible, TM joint or Petrous bone Options In Parotid Surgery

37. 38 How to address nodes (extent of LND) ? For parotid : Ipsi Level Ib, II, III, IV and Va For SM gland : Ipsi Level I, II and III

38. 39 Surgery for Submandibular gland E x cision o f the S u bm a n d ibular gla n d + SO N D

39. 40 Surgery For Minor Salivary Glands Depends on site of origin,grade & extent of disease Localized low grade tumor- Wide local excision Larger & high grade lesions- – – Marginal/segmental mandibulectomy Partial/ total resection of hard or soft palate

40. Benign tumors Superficial Parotidectomy – is recommended for most benign tumors confined to the superficial lobe, including pleomorphic adenomas

41. 42 Role Of Radiation Therapy In Salivary Gland Tumours

42. 43 No level I or level II evidence to support use of adjuvant RT Large number of prospective and retrospective studies are the guidelines for use of PORT Evidence for Adjuvant RT ???

43. Adjuvant malignant salivary gland tumor RT Supporting clinical evidence 44

44. Adjuvant malignant salivary gland tumor RT Supporting clinical evidence 45

45. Post op RT – Indications – Pleomorphic adenoma 46 Recurrent tumour Positive margin despite re-resection Deep seated tumours not amenable to complete resection Surgery will sacrifice facial nerve

46. Post op RT – Indications - Malignant 47 pT3–4 tumors High-grade tumours Mucoepidermoid carcinoma Malignant mixed tumours Adenocarcinoma Squamous cell carcinoma Close (<5mm) or Positive surgical margins Tumour adherence to or invasion of Facial nerve PNI Bone and/or connective tissue involvement LN positive (particularly if ECE +ve) After resection of recurrent disease even with negative margin

47. 48 Other Indications Of Radiotherapy PRIM A R Y 1. Large unresectable tumors 2. Medically/ surgically inoperable tumors PALLIATIVE Large , fungating masses To achieve haemostasis in bleeding tumors Recurrent tumors with exhausted available treatment modalities.

48. PORT – NECK Radiation ENI – cN0/pN0 Advanced T stage High grade histology Facial Nerve dysfunction Recurrence Intraparotid tumour, II, III Recommendation – Ib to IV - 46 – 50 Gy cN+/pN+ Level I to V 60 to 66Gy

49. 50 EBRT Techniques Conventional Three-dimensional conformal radiation therapy (3DCRT) Intensity-modulated radiation therapy (IMRT) Neutron Beam Radiotherapy

50. 51

51. Conventional Technique unilateral anterior and posterior wedged pair fields using 60 Co or 4- to 6-MV photons homolateral fields with 12- to 16-MeV electrons in combination with photons (4:1 weightage) wedged anteroposterior and posteroanterior and lateral technique with 6-MV photons

52. Unilateral field With Photon

53. En-face Unilateral field With Electron 54

54. En-face Unilateral field Photon & Electron combination

55. initial phase 56 Unilateral field Photon & Electron combination Homolateral fields with 12- to 16-MeV electrons in combination with photons 80% of the dose is delivered with electrons and 20% with 6-MV photons to spare the opposite sali v a r y gla n d, reduce muc o sitis, and decrease the skin reaction produced by electrons If deep lobe tumor  parallel opposed photon portals weighted to side of lesion in the

56. Oblique Anterior–Posterior Wedge Technique 57

57. 58 3 field photon technique Anterior (wedged), Posterior (wedge) and Lateral field Technique

58. Conformal Technique 59

59. 60

60. Post op RT in Adenoid Cystic Carcinoma Post op RT always recommended Post op RT of entire pathway of adjacent cranial nerve to base of skull always recommended Regional LN spread is 15% and elective nodal irradiation is not standard Surgery alone LCR 25-40% +RT 75%-80% In a PNI + disease, PORT decreases LRR from 15% TO 5%

61. Case scenario Example of intensity-modulated radiotherapy plan for 46-year-old woman diagnosed with Stage T2N0, left, parotid, low-grade mucoepidermoid carcinoma. No perineural invasion was found, but the tumor was within 1 mm of the surgical margin, and two major divisions of the facial nerve were splayed by the mass, requiring dissection of all its major branches. Given these pathologic and intraoperative findings, the patient was treated with adjuvant radiotherapy to the parotid bed. Contours were developed using preoperative imaging findings and in situ contralateral parotid as a guide to contour a dummy structure representing the removed parotid gland and tumor. This structure was expanded by 1–1.5 cm into the surrounding soft tissue to create the clinical target volume (CTV). The expansion was reduced at the natural barriers to tumor extension (e.g., bone) and expanded in areas at greater risk of residual disease (e.g., medially, neardeep lobe). Planning target volume (PTV) was created by uniformly expanding the CTV by 5 mm. The PTV was prescribed to 60 Gy in 30 fractions. Avoidance structures included the oral cavity (mean dose, 26.8 Gy), contralateral parotid and submandibular glands (mean doses, 6.4 and 3.6 Gy, respectively), cochlea (mean and maximal dose, 20.6 and 30.5 Gy, respectively), and spinal cord (maximal dose, 14 Gy). The maximal hot spot was 105.3%, which was within the PTV. (A) Example axial slice representing method for contouring target and avoidance structures. Representative (B) axial, (C) coronal, and (D) sagittal slices with dose distributions 62

62. 63 Submandibular Gland tumours Surgical excision Post op RT (similar indications) Elective nodal irradiation (similar indications) Technical considerations are similar Bilateral fields may be required for tumor extension toward the midline Dose : 50 Gy in 5 weeks for microscopic disease : 60 to 66 Gy in 6 to 6.5 weeks If perineural invasion

63. 64 Minor Salivary Glands Varies with location Surgical excision Palate, tongue, floor of the mouth, oral cavity, or oropharynx  Resection Posterior nasal cavity, nasopharynx, or sphenoid region  inaccessible and are mostly treated with radiation therapy Elective neck treatment is usually not indicated except for tumors of the floor of mouth, oral tongue, pharynx, and larynx. PROGNOSTIC FACTOR – (male sex, stage T3,T4, pharyngeal location and high grade). These factors are used in prognostic index. Each factor is scored 1; a prognostic index of more than equal to 2 will require neck management Irradiation : surgically inaccessible sites, aggressive tumor (positive margins, perineural spread, or bone invasion) or incomplete resection

64. 65 Neutron Therapy Slow rate of regression of advanced salivary gland tumors RTOG-MRC randomized phase III clinical trial  inoperable primary or rec u r r ent m a j o r o r m i nor s a l i v a r y glands The 10-year locoregional control probability was 17% after photon therapy, and 56% after neutron therapy Late morbidity was somewhat higher for neutron therapy.

65. Fast neutron radiotherapy is an effective treatment for locally advanced ACC of the head and neck region with acceptable toxicity. 66

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