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Pleomorphic adenoma

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2. ANATOMY Para- around otis-ear Largest salivary gland Parts superficial(80%) , deep (20%) Duct Stensens 3. HISTOLOGY 4. FACIAL NERVE 5. FACIOVENOUS PLANE OF PATEY 6. BLOOD SUPPLY: External carotid artery VENOUS DRAINAGE : External jugular vein LYMPHATIC DRAINAGE : Deep cervical nodes 7. CLASSIFICATION OF PAROTIDGLAND TUMOURS EPITHELIAL( 90%) NONEPITHELIAL Hemangioma Lymphangioma Neurofibroma MALIGNANT LYMPHOMA NHL TYPE 8. EPITHELIAL (90%) BENIGN (ADENOMAS) Pleomorphic adenoma Monomorphic adenoma Warthins tumour (adenolymhoma) Oncocytoma ( oxyphil adenoma ) Basal cell adenoma 9. EPITHELIAL ( 90% ) MALIGNANT LOW GRADE HIGH GRADE Acinic cell Adenocarcinoma carcinoma Adenoid cysticSquamous cell carcinoma carcinoma Low grade mucoepidermoidHigh grade carcinoma mucoepidermoid carcinoma 10. CASE A 45 yr old female C/0 slow growing, painlessswelling below the left side of ear forthe past 5 months O/e 5x3 cm,oval, lifting the earlobuleNo localised warmth, not tenderSurface-smooth, Margins- welldefined. Retromand groove oblit.Variable consistency. MobileNot adherent to skin, masseter muscleNo signs suggestive of facial N invExamination of oral cavity is normal 11. FNAC : shows ductal cells, chondromyxoid matrix and myoepithelial cells DIAGNOSIS : PLEOMORPHIC ADENOMA 12. PLEOMORPHIC ADENOMA MIXED TUMOUR SITE : MC: PAROTID GLAND ( 90%)- MC Tail of glandSubmandibular gland (7%)Minor salivary glands-MC : PalateOccurs more commonly in females (3:1)AGE : any age . MC : 40-50yrsUsually unilateral 13. PATHOLOGY BENIGN TUMOR Tumor capsule-well formed, but incomplete Tiny excrescences (pseudopods) project outside. Give rise to recurrences. GROSS : CUT SECTION: 14. MICROSCOPIC APPEARANCE 2 groups of cells : Well differentiated epithelialcells-acini/cords/sheets Spindle/stellate cells Abundant intercellularmucoid material-resemblescartilage Pleomorphic stroma No necrosis Rarity of mitotic figures 15. CLINICAL FEATURES Painless slow growing swelling In the parotid both lobes involved. If only deep lobeinvolved DUMB BELL TUMOUR Dysphagia if deep lobe is involved Deviation of uvula&pharyngeal wall towards midline-deep Deep lobe swelling passes through PATEYS STYLOMANDIBULAR TUNNEL Raised ear lobule Cannot be moved abv zygomatic bone-CURTAIN SIGN FACIAL NERVE NOT INVOLVED 16. INVESTIGATION FNAC IMPORTANT AND DIAGNOSTIC OPEN BIOPSY CONTRAINDICATED DUE TO : chance of injury to facial nerve, seedling & high chance of recurrence, Parotid fistula formation CT SCAN MRI 17. MANAGEMENT Tumor is RADIO RESISTANT SURGERY : ENUCLEATION avoided. High recurrence. TOC : SUPERFICIAL PAROTIDECTOMY PATEYS OPERATION( if supf lobe alone involved) TOTAL CONSERVATIVE PAROTIDECTOMY (If both lobes involved) 18. COMPLICATIONS RECURRENCE ( 1 5 %) MALIGNANCY 3-5 % IN EARLY TUMORS 10% IN LONG DURATION( >15 YRS) 19. RECURRENCE AFTER SURGERY DUE TO : Spillage Inadequate margin Retained pseudopods Multicentricity Improper technique Recurrent tumor is multinodular without capsule Marker to predict recurrence : MUC1/DF3 20. CARCINOMA IN EX PLEOMORPHICADENOMA Long standing Pl.adenoma-malignanttransformation Recent increase in size Pain , nodularity Involvement of skin, ulceration Involvement of masseter Involvement of facial nerve Neck lymph node Restriction of jaw movements 21. TAKE HOME MESSAGE MOST COMMON TUMOUR OF PAROTID FACIAL NERVE IS NOT INVOLVED TOC : SUPERFICIAL PAROTIDECTOMY FACIAL NERVE IS PRESERVED. CARCINOMA IN EX PLEOMORPHIC ADENOMA. 22. -AISHWARYA. G