Salivary neoplasm

Salivary gland neoplasm .its diagnosis and management

1. SALIVARY NEOPLASMS Presentor:Dr.S.SIVA SANKAR. Post Graduate ,Smvmch

2. 3 major salivary glands: 1. The parotid glands 2. The submandibular glands 3. The sublingual glands Other locations: lateral margin of tongue, palate, lips, buccal mucosa.

3. •The parotid gland - largest of the three major glands and weighs on average between 14 and 30 g. •Composed almost entirely of serous cells. •Sebaceous glands may be observed in 10% to 42% of normal parotid glands .

4. Parotid gland situated below the acoustic meatus between the ramus of mandible and sternomastoid muscle. The deep cervical fascia splits to form a capsule (parotid capsule) to enclose the gland Superficial part (80%)—lies over the posterior part of the ramus of mandible. Deep part (20%)—lies behind the mandible and medial pterygoid muscle; in relation to mastoid and styloid process

5. Parotid (Stensen’s) duct is 2-3 mm in diameter, 5 cm in length, begins behind the angle of the mandible, runs over the surface of the masseter muscle, passes through the buccinator muscle, and opens into the oral mucosa opposite to the crown of upper second molar tooth

6. Structures within the parotid gland from deep to superficial – • External carotid artery, maxillary artery, superficial temporal artery, posterior auricular artery • Retromandibular vein (by maxillary and superficial temporal veins) • Facial nerve with its branches

7. FACIAL NERVE Facial nerve emerges from the stylomastoid foramen lying between external auditory meatus and mastoid process. It passes around the neck of the condyle of mandible and becomes superficial, later dividing into temporofacial and cervicofacial branches which in turn divides into many branches. Some of these may be interconnected as pes anserinus (goose foot).

8. SUBMANDIBULAR GLAND The submandibular gland is the second largest salivary gland, weighing approximately 7 to 8 g. •Mixed, with both serous and mucous cells; serous units predominate, accounting for approximately 90% of the acinar cells.

9. It is a ‘J’ shaped salivary gland situated in the anterior part of the digastric triangle. Superficial part Lies in submandibular triangle, superficial to mylohyoid and hyoglossus muscles, between the two bellies of digastric muscle. • Deep part is in the floor of the mouth and deep to the mylohyoid.

10. Submandibular (Wharton’s) duct ,5 cm in length, emerges from the anterior end of the deep part of the gland, enters the floor of the mouth, on the summit of papilla beside the frenulum of the tongue.

11. Important anatomical relationships of the submandibular glands ● Lingual nerve ● Hypoglossal nerve ● Anterior facial vein ● Facial artery ● Marginal mandibular branch of the facial nerve

12. SUBLINGUAL GLAND Sublingual gland is poorly encapsulated, smallest major salivary gland, weighing approximately 2 to 3 gm. located in the anterior aspect of the floor of the mouth in relation to mucosa, mylohyoid muscle, body of the mandible near mental symphysis. Gland drains directly into mucosa or through a duct which drains into submandibular duct( Bartholin duct.)

13. Minor salivary glands There are around 450 minor salivary glands which are distributed in lips, cheeks, palate and floor of the mouth. Glands also may be present in oropharynx, larynx, trachea and paranasal sinuses. They contribute to 10% of total salivary volume

14. SALIVARY TUMOURS

15. WHO CLASSIFICATION

16. Incidence • 80% salivary neoplasms are in the parotids of which 80% are benign. 80% of these are pleomorphic adenomas. • 15% of salivary tumours are in the submandibular salivary gland, of which 50% are benign. 95% of these are pleomorphic adenomas. • Ten percent of salivary neoplasms are in the minor salivary glands—palate, lips, cheeks, and sublingual glands. Of these only 10% are benign.

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

18. PLEOMORPHIC ADENOMA (Mixed salivary tumour) Commonest of the salivary gland tumour. • It is 80% common. • More common in parotids (80%). • It is mesenchymal, myoepithelial and duct reserve cell origin. Grossly it contains cartilages, cystic spaces, solid tissues .

19. Clinical features of parotid tumour • Raised ear lobule • Cannot be moved above the zygomatic bone— curtain sign • Deviation of uvula and pharyngeal wall towards midline in case of deep lobe tumour • Facial nerve, masseter, skin, lymph node and bone involvement eventually occurs in case of malignancy

20. Present as a single painless, smooth, firm lobulated, mobile swelling in front of the parotid. Positive curtain sign (As the deep fascia is attached above to the zygomatic bone, it acts as a curtain, not allowing the parotid swelling to move above that level. Any swelling superficial to the deep fascia will move above the zygomatic bone.). • Obliteration of retromandibular groove is common.

21. Long-standing pleomorphic adenoma may turn into carcinoma . Its features are: • Recent increase in size • Pain and nodularity • Involvement of skin, ulceration • Involvement of masseter

22. Involvement of facial nerve—Lower facial nerve palsy—(Difficulty in closing eyelid, difficulty in blowing and clenching teeth) • Involvement of neck lymph node

23. Investigations • FNAC is very important and diagnostic. • CT scan to know the status of deep lobe, local extension and spread. • MRI is better method. Incision biopsy of parotid tumour is contraindicated as chances of seedling and recurrence are high and also there is a chance of injuring the facial nerve while doing the biopsy.

24. Treatment • Surgery—First line treatment. • If only superficial lobe is involved, then superficial parotidectomy is done wherein parotid superficial to facial nerve is removed. • If both lobes are involved, then total conservative parotidectomy is done by retaining facial nerve.

25. ADENOLYMPHOMA (Warthin’s Tumour, Papillary Cystadenolymphomatosum) It is a benign tumour that occurs only in parotid, usually in the lower pole. • It is said to be due to trapping of jugular lymph sacs in parotid during developmental period.

26. It presents as a slow growing, smooth, soft, cystic, fluctuant swelling, in the lower pole, often bilateral and is nontender. • It is common in males – 4:1. • Common in old people – 60 years. • Its incidence is 10%.

27. Adenolymphoma produces a “hot spot” in 99Technetium pertechnetate scan—it is diagnostic (Due to high mitochondrial content). • FNAC. Adenolymphoma does not turn into malignancy.

28. Treatment Superficial parotidectomy.

29. Malignant salivary gland tumours are divided into two distinct sub-groups: 1 Low-grade malignant tumours (e.g. acinic cell carcinoma) are indistinguishable on clinical examination from benign neoplasms.

30. 2.High-grade malignant tumours usually present as rapidly growing, often painless swellings in and around the parotid gland. The tumour presents as either a discrete mass with infiltration into the overlying skin or a diffuse but hard swelling of the gland with no discrete mass. Presentation with advanced disease is common, and cervical lymph node metastases may be present. Among primary parotid malignant tumours, mucoepidermoid carcinoma is the most common, followed by adenocystic carcinoma.

31. MUCOEPIDERMOID TUMOUR • It is the commonest malignant salivary gland tumour (in major salivary glands). It is slowly progressive, often attains a large size and spreads to neck lymph nodes. • It contains malignant epidermoid and mucus secreting cells.

32. Types • Low grade—mucus cells mainly. • High grade—epidermoid cells mainly. Facial nerve involvement is late in mucoepidermoid carcinoma of parotid.

33. Clinical Features • Swelling in the salivary (parotid or submandibular) region, slowly increasing in size, eventually attaining a large size, which is hard, nodular, often with involvement of skin and lymph nodes.

34. ADENOID CYSTIC CARCINOMA 10% of salivary tumours • It is common in submandibular and minor salivary glands. • It consists of myoepithelial cells and duct epithelial cells with cribriform or lace like appearance. • It involves facial nerve very early, spreads through the perineural sheath and infiltrates into the perineural tissues over a long distance, more proximally. • It also invades periosteum and bone medulla early and spreads extensively. • Prognosis is poor. • Radical parotidectomy and radical radiotherapy is the treatment of choice.

35. ACINIC CELL TUMOUR • It is a rare, slow growing tumour that occurs almost always in parotid and is composed of cells alike serous acini. It is more common in women. It occurs in adult and elderly. • It can involve facial nerve or neck lymph nodes. • Clinically it is of variable consistency with soft and cystic areas. • It is low grade malignant tumour.

36. GENERAL FEATURES OF MALIGNANT SALIVARY TUMOURS 1. Fixation 2. Resorption of adjacent bone 3. Pain and anaesthesia in the skin and mucosa 4. Muscle paralysis 5. Skin involvement and nodularity 6. Involvement of jaw and masticatory muscle 7. Nerve involvement (facial nerve in parotid or hypoglossal nerve in submandibular salivary gland)

37. 8. Blood spread when occurs, commonly to lungs 9. Mandibular branch of 5th cranial nerve may be involved when tumour tracks along the auriculotemporal nerve to the base of the skull causing severe pain in the distribution area.

38. PAROTID LYMPHOMA • Parotid lymphoma can occur from the lymph nodes in the gland or from parotid parenchyma. • It can occur in HIV patients; lymphoepithelial diseases and in Sjogren’s syndrome. • Common in elderly. • Disease may be confined to parotid gland or may involve other nodes in neck, mediastinum. • When it is confined to parotid total parotidectomy with radiotherapy and later chemotherapy is the treatment. • When many other nodes are involved chemotherapy is the choice therapy.

39. MANAGEMENT OF MALIGNANT SALIVARY TUMOURS

40. TNM Staging of Malignant Salivary Tumours Tx —Tumour cannot be assessed. T0 —No evidence of primary tumour. T1 —Tumour < 2cm without extraparenchymal spread. T2 —Tumour 2-4 cm. T3 —Tumour 4-6 cm. —or with extraparenchymal spread. —but no facial nerve spread.

41. T4 —Tumour > 6 cm. —or spread to facial nerve, skin, mandible, ear canal (T4a.) —or spread to base of skull, pterygoid plates, encased external carotid artery (T4b.)

42. N—Lymph node Nx —Nodes not assessed. N0 —Regional nodes not involved. N1 —Single ipsilateral node < 3 cm. N2a —Single ipsilateral node 3-6 cm. N2b —Multiple ipsilateral nodes < 6 cm. N2c —Bilateral or contralateral nodes < 6 cm. N3 —Single node spread > 6 cm. M—Metastases M0 —No blood spread. M1 —Blood spread present.

43. Specific Investigations 1. FNAC. 2. CT scan to see the deep lobe of the parotid: the involvement of bone, extension into the base of the skull; relation of tumour to internal carotid artery, styloid process. 3. OPG. 4. Blood grouping and cross matching; required amount of blood is kept ready. 5. FNAC of lymph node. 6. MRI shows better soft tissue definition than CT scan.

44. Surgery – Radical parotidectomy removal of both lobes of parotid, soft tissues, part of the mandible with facial nerve. – Facial nerve is reconstructed using greater auricular nerve, or sural nerve.

45. PAROTIDECTOMY 1. Superficial parotidectomy: It is the removal of superficial lobe of the parotid (superficial to facial nerve). Done in case of benign diseases of superficial lobe of the parotid.

46. 2.Total conservative parotidectomy: It is done in benign diseases of parotid involving either only deep lobe or both superficial and deep lobes. Here both lobes are removed with preservation of facial nerve. Initially superficial parotidectomy is done and facial nerve and its branches are retracted gently and deep lobe is removed.

47. 3.Radical parotidectomy: Both lobes of parotid are removed along with facial nerve, fat, fascia, muscles,(masseter, pterygoids and buccinator) lymph nodes. It is done in case of carcinoma parotid. Later facial nerve reconstruction is done using great auricular nerve graft.

48. Suprafacial parotidectomy Suprafacial parotidectomy is done in lower pole parotid tumours wherein all branches of the facial nerve need not be dissected

49. Steps in parotidectomy • Lazy ‘S’ incision and raising the skin flaps • Mobilisation of the gland • Identification of facial nerve trunk • Dissection of the gland off the facial nerve using bipolar cautery • Removal of parotid – superficial / both • Distilled water (hypertonic) irrigation to kill spilled tumour cells • Haemostasis and closure with a suction drain

50. LAZY S INCISION

51. LOCATION OF THE FACIAL NERVE TRUNK 1 the inferior portion of the cartilaginous canal. This is termed Conley’s pointer (tragal pointer) and indicates the position of the facial nerve, which lies 1 cm deep and inferior to its tip; 2 the upper border of the posterior belly of the digastric muscle. 3 the squamotympanic fissure; 4 the styloid process (the nerve is superficial to it); 5 the mastoid process can be drilled and the nerve identified more proximally.

52. Complications of surgery: 1. Haemorrhage 2. Infection, flap necrosis 3. Fistula 4. Frey’s syndrome 5. Facial nerve palsy 6. Facial numbness 7. Numbness in ear lobule due to injury to great auricular nerve 8. Sialocele

53. Postoperative radiotherapy is useful to reduce the chances of relapse. Usually, external radiotherapy is given. It is given in all carcinomas, but more useful in adenoid cystic and squamous cell carcinomas. • Chemotherpy is also given. Drugs given here depends on tumour type. Intra-arterial chemotherapy is beneficial. • Preoperative radiotherapy is given in large tumours to down stage the disease.

54. If lymph nodes are involved, which is confirmed by FNAC, radical neck dissection is done. It is also done in N0 with high-grade tumour or T3/T4 tumours.

55. Indications for radiotherapy in malignant salivary gland tumours: 1. All adenoid cystic and adenocarcinomas 2. T3 and T4 tumours 3. Recurrent tumours 4. Poorly differentiated tumours – high grade 5. Tumours with lymph node involvement 6. As preoperative radiotherapy 7. Recurrent benign pleomorphic adenomas 8. Spillage during surgery in case of pleomorphic adenomas 9. Residual tumours, refractory tumour or nerve involvement 10. When clearance margin is inadequate

56. SUBMANDIBULAR SALIVARY GLAND TUMOURS Benign tumours: They are commonly pleomorphic adenomas. are smooth, firm or hard, bidigitally palpable, without involving adjacent muscles or hypoglossal nerve or mandible bone. Diagnosis FNAC, Orthopantomogram (OPG) and CT scan. Excision of both superficial and deep lobes of the gland is done.

57. Malignant tumours of submandibular salivary gland: • They are hard, nodular, often get fixed to skin, muscles, hypoglossal nerve and mandible. • Diagnosis is by FNAC of primary tumour and of lymph nodes when involved, CT scan and OPG. Treatment: Wide excision, with removal of adjacent muscle, soft tissues and mandible. If lymph nodes are involved, block dissection of neck (Classical neck dissection) is done.

58. Steps in submandibular salivary gland excision • Anaesthesia – general • Position – neck extension with chin to opposite side • Incision – 2-4 cm (3 cm) below and parallel to the margin of the mandible 5-8 cm in length (6 cm) • Mobilisation of the gland intracapsular in sialadenitis; extracapsular in tumours with ligation of anterior facial vein Facial artery ligation proximally and distally as artery is in the gland or in the groove posteriorly

59. Dissection of deeper lobe from mylohyoid muscle Identification of lingual and hypoglossal nerves Duct identification and ligation Wound closure with a suction drain

60. MINOR SALIVARY GLAND TUMOURS • It is 10% of salivary tumours. • It is common in — palate (40%), lip, cheek, sublingual glands. • 10% are benign—commonly pleomorphic adenomas. • 90% are malignant—commonly adenoid cystic carcinomas. • They present as swelling with ulcer over the summit. • If it is malignant, then extension into the palate, maxilla, pterygoids can occur often with involvement of the lymph node

61. Investigations 1. Incision biopsy. 2. CT Scan. 3. X-ray maxilla. 4. FNAC of lymph node.

62. Treatment • Wide excision often with palatal excision or maxillectomy is done for malignancy. • Reconstruction by dental plates, skin grafting, or flaps are done. • Lymph node block dissection of the neck is done if involved. • Excision with primary closure is done for benign tumours.

63. • Salivary gland tumours are usually benign in an adult. • It is rare in children but when it occurs, it is commonly malignant. • Clinical and FNAC are diagnostic methods. • Open biopsy is contraindicated. • Sialogram is not useful in salivary tumours. • CT scan or MRI are often needed. • Nerve should be preserved in benign lesions. • Nerve can be sacrificed to achieve clearance in malignancies.