Salivary gland tumor

SALIVARY GLAND TUMORS
CLASSIFICATIONS
DIAGNOSIS AND TREATMENT

1. Salivary gland tumors DR.MAMOON AMEEN

2. Introduction Marked morphological diversity, and are thus highly prone to diagnostic confusion The majority of these neoplasms are benign 80% and only 20% are malignant. The various types of salivary gland tumors are best distinguished by their histologic patterns.

3. Classification Benign Pleomorphic adenoma Warthin’s tumor Oncocytoma Lymphangioma Haemangioma canalicular adenoma, basal cell adenoma myoepithelioma Malignant Mucoepidermoid carcinoma Adenoid cystic carcinoma Carinoma ex- pleomorphic adenoma Acinic cell ca Adenocarcinoma Salivary ductal carcinoma Squamous cell carcinoma Non- hodgkin’s lymphoma

4. EPIDEMIOLOGY 2-3%of all head and neck neoplasms. Benign tumors account for 63% to 78% of all salivary gland neoplasms. (64%-80%), in the parotid glands ,malignancy (15%- 32%). 7-11% occur in the submandibular glands, malignancy (37% - 45%). less than 1% in the sublingual glands, malignancy (70%-90%), 9%-23% in the minor glands.

5. Rule of 80’s: -80% of salivary gland tumors occur in the parotid 80% of parotid tumors are benign -80% of parotid tumors are Pleomorphic adenomas -80% of parotid Pleomorphic adenomas occur in the superficial lobe -80% of untreated Pleomorphic adenomas remain benign

6. Etiologic Factors Radiation exposure Genetic predisposition Tobacco Chemical carcinogens Viruses

7. PLEOMORPHIC ADENOMA Most common of all salivary gland neoplasms 80-90% of parotid tumors Of the minor salivary glands most commonly occurs in the palate ,upper lip 4th-6th decades M:F = 1:3-4

8. PLEOMORPHIC ADENOMA Slow-growing, painless , firm mass Encapsulated Mixed tumor: contains both epithelial and mesenchymal elements It sends pseudopod-like extensions ‘into surrounding tissue Malignant transformation is 10% if observed for more than 15 years.

9. Because most of the tumors arise from the superficial lobe, a superficial parotidectomy is often required. Recurrent pleomorphic adenoma is an uncommon but challenging problem. There are frequently multiple foci of recurrence that may continue to manifest over several years.

10. W arthin’s tumor( papillary cystadenoma lymphomatosum ) 2 nd most common after pleomorphic adenoma Commonly seen 7 th decade Male: female (7:1) Associated with cigarette smoking Almost Exclusively in parotid gland Parotid tail 10% bilateral

11. Usually Fluctuant, slow growing Encapsulated cystic lesion Histologically: epithelial & lymphoid elements Never malignant W ide local excision parotidectomy with facial nerve preservation

12. Oncocytoma (oxyphil adenoma) Rare 1 % of benign salivary tumor 6 th decade No gender predilection Parotid ,Submandibular gland Minor salivary glands: palate, buccal mucosa, Slow growing ,painless The treatment of choice for is surgical excision.

13. Malignant neoplasms Shorter duration Grow rapidly or history of slow growth with sudden rapid activity Fixed to surrounding tissues Overlying skin or mucous membrane may be ulcerated or inflamed Surface telangiectasia Nerve involvement Regional lymph nodes may be enlarged

14. Mucoepidermoid Carcinoma 2 nd most common salivary gland tumor Most common salivary gland malignancy Parotid 80% - 90% of cases Age: 5th – 7 th decades Gender: slight female predilection Site: parotid gland, palate Etiology: radiation exposure

15. It contain two major elements: mucin producing cells & epithelial cells of epidermoid variety & according to that classified into Low grade Intermediate High grade Low-grade: slow growing, painless mass High-grade: rapidly enlarging, +/- pain

16. Adenoid cystic carcinoma( Cylindroma ) 2 nd most common salivary gland malignancy Infiltrates widely into the tissue planes & muscles Perineural spread Commonly in submandibular gland , sublingual or minor salivary glands Slow growing but aggressive neoplasm with a remarkable capacity of recurrence.

17. Infrequent cervical metastases High degree of late distant metastases Treatment Complete local excision Tendency for perineural invasion: facial nerve sacrifice Postoperative RT Prognosis Local recurrence: 42% Indolent course: 5-year survival 75%, 20-year survival 13%

18. ACINIC CELL CARCINOMA 6% to 8% of all salivary malignancies Mostly in parotid 3% Shows bilateral involvement Has a low-grade behavior Associated with the best survival rate of any salivary malignancy

19. ACINIC CELL CARCINOMA They seldom metastasize but they have high tendency to recur locally Primary treatment is complete surgical resection with neck dissection limited to the therapeutic setting. Postoperative radiation is not routinely advised

20. Carcinoma ex-pleomorphic adenoma Malignant degeneration can occur in 3% to 7 % of pleomorphic adenomas. Parotid > submandibular > palate Risk of malignant degeneration 1.5% in first 5 years 9.5% after 15 years Typical history of slowly growing mass demonstrating sudden increase in the growth.

21. Treatment Radical excision Neck dissection (25% with lymph node involvement at presentation) Postoperative XRT

22. Polymorphous Low-Grade Adenocarcinoma 2 ND most common malignant intraoral tumor of the salivary glands. Palate (60-70%) > buccal mucosa (16%) > upper lip, retromolar area, base of tongue. F:M = 2:1 & common in 5 th to 7 th decade. A painless mass in the palate is the most common presentation.

23. SALIVARY DUCT CARCINOMA High grade aggressive tumor from excretory duct cells in major salivary gland mainly Microscopic feature remarkably similar to mammary intraductal carcinoma 35% recurrence 62% distant metastasis Neural invasion and extraglandular extension are commonly seen. Most patients die within three years.

24. SALIVARY DUCT CARCINOMA

25. ADENOCARCINOMA: Ranging from low grade well differentiated to high grade invasive lesions Common in major glands Originate from excretory or striated ducts Cystic or solid, may be papillary or non-papillary in growth pattern Prognosis depend on grade

26. SQUAMOUS CELL CARCINOMA Rare to be primary & common to be secondary from intraparotid lymph node or direct involvement Should be differentiated from mucoepidermoid carcinoma by presence of mucin on electronmicroscope with stain or immunohistochemical test Incidence 0.3% -1.5% in major gland 50% nodal metastasis M:F = 2:1 7th-8th decades TR: Surgery + Neck dissection + Postop. RT

27. LYMPHOMA: 5% of all extranodal lymphoma affect salivary gland 90% occur in parotid 85% are N H L Its risk in Sjogren’s syndrome is 44 fold higher

28. SECONDARY TUMORS: The majority of metastasis are caused by lymphatic spread from cutaneous malignancy of the head & neck Hematogenous metastasis are rare & majority from lung, kidney & breast Contiguous extension of facial sarcomas 10% of malignant parotid gland tumors 40% are SCC, & 40% are melanoma

29. STAGING

30. STAGING: Stage I T1N0M0 Stage II T2N0M0 Stage III T3N0M0 or T1-3 N1M0 Stage IVA T4aN0-1M0 or T1-4a N2M0 Stage IVB T4bNxM0 or TxN2-3M0 Stage IVC TxNxM1

31. Evaluation of patient History Important points in the history Mass (duration, rate of the growth, presence of pain) Facial paralysis, B/L Cervical lymphadenopathy Eyes and joints symptoms H/O exposure to radiation Ipsilateral weakness or numbness of tongue

32. Examination:- Size of the mass Overlying skin, Skin fixation, mobility Lymphadenopathies Cranial nerves Intraoral examination

33. Investigations USG X ray chest  OPG To R/O mandibular involvement. CT SCAN MRI

34. USG Distinguish intrinsic from extrinsic tumors It can be used to differentiate solid from cystic masses in the salivary glands USG guided FNAC

35. CT/MRI Anatomical localization Local, regional ,distant invasion MRI IS BETTER ?? Excellent assessment of margins Deep extension and infiltration Bone marrow invasion Perineural spread Intracranial extension

36. Fine-Needle Aspiration Biopsy Accuracy well established Sensitivity = 54-95% Specificity = 86 - 100% Confirms possibility Lymphoma/inflammatory masses. Allows preoperative assesment of Nature of tumour Extent of resection (conservative/radical) Management of facial nerve (high grade adenoid cystic) Likelihood of neck dissection (high grade).

37. Open biopsy Contraindicated Justified in minor salivary gland tumor Ulcerated lesion where fine needle aspiration cytology suggests lymphoma, In cases of diffuse salivary enlargement

38. Frozen section may be useful when preoperative FNA is non-diagnostic, when the FNA diagnosis is at odds with the clinical and/or intraoperative findings The results of frozen section may help in intraoperative decision-making. In cases where frozen section shows high-grade carcinoma, the surgeon may proceed to perform at least a limited neck dissection with the parotidectomy

39. MANAGEMENT TREATMENT Surgery Radiotherapy Chemotherapy Factors that influence treatment Age Metastatic spread Facial nerve involvement Mandibular / Temporal bone involvement Skin Site of tumor Size, Extent, Grade & stage

40. Benign salivary gland tumors should be excised completely with an adequate margin to avoid local recurrences Simple enucleation not appropriate treatment recurrence rate 21-45% 1 cm margin has been shown to be adequate. Cutting into the tumour should be absolutely avoided as it can lead to tumor spillage Surgery Benign tumors

41. Surgery Benign tumors Superficial parotidectomy partial superficial parotidectomy, Deep lobe tumors -Total parotidectomy with facial nerve preservation. Parapharyngeal tumors -cervical-parotid approach and with or without a mandibulotomy.

42. Surgery Benign tumors A tumor of the submandibular gland requires submandibular gland resection If the tumor originates from a minor salivary gland, the tumor and a cuff of normal tissue should be excised.

43. Surgery Malignancies The mainstay of treatment for salivary carcinomas is surgical resection with or without postoperative radiotherapy The extent of surgery is dependent on the size and site of the tumour The goal of surgical treatment is to achieve local control As a general rule, every effort should be made to preserve a nerve which was functioning normally preoperatively

44. Surgery Facial nerve sacrifice should be reserved for cases of preoperative paralysis, cases of recurrent malignancy gross encasement and infiltration of the nerve

45. Surgery  Parotid Gland:   Size and location determine extent of resection Most T1/T2 lesions lateral to the nerve are suitable for a superficial parotidectomy   with adequate margin 1.5cm Larger and deep lobe tumours usually require a total conservative parotidectomy with preservation of the facial nerve Patients with high grade and extensive disease (i.e. skin involvement or facial palsy) may require extended radical parotidectomy 

46. Superficial parotidectomy : Removal of superficial lobe of the parotid (superficial to facial nerve)

47. RADICAL PAROTIDECTOMY Removal of Both lobes of parotid Facial nerve Mandibular ramus Masseter muscle Infratemporal fossa dissection Subtotal petrosectomy

48. Complications of parotid surgery Facial nerve injury HEMATOMA Salivary fistulas Infection : Flap necrosis is common Frey’s syndrome Sialocele Numbness over the face and ear

49. Neck dissection Neck dissection should be performed in patients with clinical or radiological evidence of nodal disease A prophylactic selective neck dissection should be considered for patients with high-stage or high-grade

50. Radiotherapy Primary treatment for salivary carcinomas is limited to unresectable tumours Postoperative radiotherapy is indicated for: Tumours greater than 4 cm, Presence of positive surgical margins or Facial nerve were preserved despite being adherent to the tumour , lymph node metastases High grade tumor perineural invasion. Recurrent pleomorphic adenoma Spillage after surgery for pleomorphic adenoma

51. Radiotherapy Preoperative radiotherapy Given in large tumours to reduce the size and make it better operable, i.e. to down stage the disease

52. Prognosis Advanced stage, higher histologic grade _____poor prognosis submandibular location _____________________poorer outcome 10 yr survival rates for stage I ____82% II____ 64% III ____50% IV ____33% Regional lymph node metastases ______poorer prognosis

53. Prognosis Distant metastases _________________ poor prognosis Parapharyngeal space extension _____poor prognosis Parotid malignancies ________________ better prognosis Facial nerve paralysis ________________ poor prognosis

54. Thank you