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Start with the name of ALLAH
MALIGNANT SALIVARY GLAND NEOPLASM
DR. TARIQ JAVEDFCPSII Resident @
ORAL & MAXILLOFACIAL SURGERYNISHTAR INSTITUTE OF DENTISTRY,
MULTAN,[email protected]
Contents HISTORY OF SALIVARY GLANDS EMBROLOGOY TYPES OF SALIVERY GLANDS Anatomy Tumors of salivary glands Incidence of salivary gland tumors Etiology Path physiology Diagnostic Procedures MALIGNANT TUMORS, DISCRIPTION & MANAGMENT
SALIVARY GLANDSHISTORY
RIOLAN 1648: Identified the glandular substance of the parotid.
NIELS STENSON 1660: Identified the parotid duct in sheep’s head.
THOMAS WARTON 1656 - Identified the submandibular gland and duct.
Salivary glandsTwo types of SGs
1- Major Paired SG-Parotid-Submandibular-Sublingual
2- Minor salivary glandThe minor salivary glands comprise 600-
1000 small glands distributed throughout the upper aerodigestive tract.
They secrete mucous secretions except von-ebner gland.
They have numerous small ducts.
PAROTID GLAND
Largest salivary gland Weighs about 28g Pyramidal in shape Predominantly Serous Secretion
THE PAROTID DUCT LIES ON AN IMAGINARY LINE BETWEEN THE
EXTERNAL NARES AND THE TRAGUS OF THE EAR.
ANATOMY OF PAROTID GLAND
ANATOMY - PAROTID
Boundaries are the external auditory canal, ramus of the mandible and mastoid process.
Stensen’s duct – Runs along anterior border of the masseter muscle pierce through the buccinator muscle and enters intraorally along side the maxillary second molar.
ANATOMY – (contd)
GLAND IS ENCASED IN A SHEATH.ARTIFICIAL DIVISION BETWEEN THE DEEP
AND SUPERFICIAL LOBE.FACIAL NERVE DIVIDES THESE “LOBES”.
•Superficial•Deep
FACIAL NERVE
Exits from the stylomastoid foramen. Divides into a temporofacial and
cervicofacial branch. Terminal branches:
TEMPORAL/FRONTAL ZYGOMATICO-ORBITAL BUCCAL MANDIBULAR CERVICAL
ANATOMY - SUBMANDIBULAR
GLANDPaired StructuresThe lies along the posterior border of the
mylohyoid muscle.WHARTON’S DUCT - Travels along the
posterior border of the mylohyoid muscle and opens intraorally at the ipsilateral sublingual papilla adjacent to the anterior midline on the floor of the mouth.
ANATOMY - SUBLINGUAL GLAND
Boundaries on the lingual surface of the anterolateral mandible
20 ducts which drain into the anterior floor of the mouth
BARTHOLIN DUCT - Coalescence of some of these ducts into a more defined duct. Bartholin’s duct may empty into wharton’s duct.
ANATOMY –MINOR SALIVARY GLANDS
Located on: LIPS PALATE BUCCAL MUCOSA TONGUE FLOOR OF THE MOUTH.
TUMOR
Abnormal mass of tissue, the growth of which exceeds and is incordinated with that of normal tissues.
NEOPLASMS ARISING IN THE SALIVARY GLANDS ARE RELATIVELY RARE, YET THEY
REPRESENT A WIDE VARIETY OF BOTH BENIGN AND MALIGNANT HISTOLOGIC
SUBTYPES .OVER THE YEARS, DIAGNOSIS AND TREATMENT OF SALIVARY GLAND
NEOPLASMS REMAIN COMPLEX AND CHALLENGING PROBLEMS FOR THE ORAL
AND MAXILOFACIAL SURGEON.
Salivary gland neoplasm
TUMORS OF THE SALIVARY GLANDS
INCIDENCE: 3/100,0003% of all body tumorsLOCATION OF SALIVARY GLAND
TUMORS: 85% PAROTID, 10% SUBMANDIBULAR,
1% SUBLINGUAL, 4-5% MINOR SALIVARY GLANDS
BENIGN MALIGTPAROTID 85% 10-15%SUBMANDIBULAR 45% 55%SUBLINGUAL 10-15% 85%
A useful rule of thumb is the
25% /50% /75% rule.That is, as the size of the gland
decreases, the incidence of malignancy of a tumor in the gland increases, in approximately these proportions.
Evaluation of a patient with a suggested salivary gland neoplasm must begin with a thorough medical history and physical examination.
Patients with malignant lesions typically present after age 60 years, whereas those with benign lesions usually present when older than 40 years.
Benign neoplasm's occur more frequently in women than in men, but malignant tumors are distributed equally between the sexes.
Most series report that about 80% of parotid neoplasms are benign, with the relative proportion of malignancy increasing in the smaller glands. The most common tumor of the parotid gland is the pleomorphic adenoma, which represents about 60% of all parotid neoplasms
Almost half of all submandibular gland neoplasms and most sublingual and minor salivary gland tumors are malignant.
Incidence in children
Salivary gland neoplasms are rare in children
65% are benign (hemangiomas being the most common, followed by pleomorphic adenomas)
35% of salivary gland neoplasms are malignant. Mucoepidermoid carcinoma is the most common salivary gland malignancy in children
Successful treatment
Successful diagnosis and treatment of patients with salivary gland tumors require a thorough understanding of tumor etiology, biologic behavior of each tumor type, and salivary gland anatomy.
HISTORY OF LESION
A LENGTH OF TIME MASS PRESENT AND history of prior cutaneous lesion or parotid lesion excision
Slow-growing masses of long-standing duration tend to be benign.
A history of
Squamous cell carcinoma, malignant melanoma, or malignant fibrous histiocytoma suggests intraglandular metastasis or metastasis to parotid lymph nodes.
Prior parotid tumor most likely indicates a recurrence because of inadequate initial resection.
PRESENTING COMPLIANTS
TRISMUSTrismus often indicates advanced disease
with extension into the masticatory muscles or invasion of the temporomandibular joint.
Pain is also a common problem esp; adenoid cystic carcinoma.
Occasionally occurring in early in course of disease, before any swelling
PRESENTING COMPLIANTS
Dysphagia or a sensation of a foreign body in the oropharynx indicates a tumor of the deep lobe of the gland.
Ear pain A complaint of ear pain may indicate extension of the tumor into the auditory canal.
Numbness The presence of numbness in the distribution of the second or third divisions of the trigeminal nerve often indicates neural invasion.
Physical examination of the Head & Neck must be thorough and complete. The entire head and neck must be examined for cutaneous lesions, which may be caused by metastasis from the parotid gland or parotid nodes
Palpation
Degree of firmness. Even benign tumors usually are firm, but a rock-hard mass generally denotes malignancy.
Skin fixation, skin ulceration, or fixation to adjacent structures also indicates malignancy.
The external auditory canal must be visualized for tumor extension
Palpation
All regional nodes must be carefully palpated to detect nodal metastasis. Examination of the oral cavity and oropharynx also may yield further evidence of metastasis or malignant nature of the lesion
Blood or pus from Stenson duct are signs of malignancy, but are infrequently encountered. More often, one may see bulging of the lateral pharyngeal wall or soft palate, indicating tumor in the deep lobe of the gland.
Once a thorough history and physical examination are complete, perform diagnostic procedures to confirm the diagnosis and extent of the disease process.
Diagnostic Procedures
Fine needle aspiration Fine needle aspiration of the mass or
a suggestive lymph node may be performed to obtain a tissue diagnosis
Fine needle aspiration
The sensitivity of this procedure is greater than 95% in experienced hands.
However, only a positive diagnosis should be accepted.
False negative results indicating the need for further attempts at obtaining a histologic diagnosis.
Including repeat FNAC
Fine needle aspiration
If fine needle aspiration is unsuccessful in obtaining a diagnosis, an Incisional Biopsy should not be performed.
This procedure has a high rate of local recurrence and places the facial nerve at risk for injury from inadequate visualization.
Fine needle aspiration
Some authors advocate large core needle biopsies, but this procedure is less popular because of potential facial nerve injury and theoretical seeding of the needle tract with tumor cells
Frozen Section
Intraoperatively, frozen section of the specimen should be submitted for diagnosis.
The use of frozen sections has demonstrated greater than 93% accuracy in the diagnosis of parotid malignancy
Imaging studies
Imaging studies are very helpful in staging and surgical planning.
Sialography is mentioned for historic interest only. Although it may help differentiate inflammatory versus neoplastic processes, sialography is infrequently performed and is of limited value in the evaluation of parotid masses
Imaging studies
CT scan and MRI have become invaluable tools in the evaluation of parotid malignancies.
MRI
MRI demonstrates the mass in greater contrast than CT scan, but CT scanning provides better detail of the surrounding tissues.
These imaging studies may identify regional lymph node involvement or extension of the tumor into the deep lobe or parapharyngeal space
CT scan
CT scan criteria for lymph node metastasis include any lymph node larger than 1-1.5 cm in greatest diameter, multiple enlarged nodes, and nodes displaying central necrosis
Lymph nodes harboring metastasis also may appear round rather than the normal kidney bean shape, and evidence of extracapsular extension may be identified.
Classification of salivary tumors
BenignPleomorphic adenomaMyoepitheliomaWarthin tumorOncocytomaPapillary cystadenomaDuctal papilloma
Malignant
Mucoepidemoid carcinomaAdenoid cystic carcinomaAcinic cell carcinomaMalignant mixed tumorSquamous cell carcinomaAdenocarcinomaOncocytoma
MALIGNANT MASSES
PROGNOSIS:
PAROTID >> SUBMANDIBULAR / SUBLINGUAL GLAND
5th -6th DECADERATE OF GROWTH DOES NOT CORRELATE
WITH THE DEGREE OF MALIGNANCYLUNG and BONE: PRIMARY METASTATIC
SITESPRIOR RADIOTHERAPY INCREASES THE
RISK OF A SALIVARY GLAND MALIGNANCY.
MUCOEPIDERMOID CARCINOMA
MUCOEPIDERMOID CARCINOMA
One of the most common salivary gland malignancies.
1- 2% of major salivary gland.9% of minor salivary gland tumors.Wide range 2nd to 7th decade of life.Mucous and epidermoid cell origin.6% of all parotid tumors and is most
common malignancy.65% found in the parotid gland.18% of all malignant tumors of the
salivary glands.
FEATURES
Appear as asymptomatic swelling
8% CN VII involvement at the time of presentation
<10% Lymph node metastasis
HISTOLOGY
LOW gradeShows prominent cysts, minimal cellular
atypia, high proportion of mucous cells HIGH GRADES
Solid islands of squamous and intermediate cells
Mitotic activity is more INTERMEDIATE
fall in b/w low and high grade.Cyst formation occur but less prominent.Intermediate cell are prominent
TREATMENT:
Total glandular resection +/- neck node dissection
Cn VII: Spare nerve unless involved with tumor.
Postoperative radiotherapy depending on margins, extracapsular extension from lymph nodes, perineural involvement, or involvement of surrounding structures
RECURRENCE
Recurrence rate 15-25%, usually due to inadequate resection.
Mucuoepidermoid carcinoma is more aggressive in the submandibular gland.
Rarely involves the sublingual gland
Intraosseous mucoepidemoid carcinoma
Very rare Most common and best recognized
intrabony salivary gland tumorMiddle aged /adult3 times more common mandible than
maxillaMolar ramus regionCortical swelling, pain parasthesiaSurgical Excision
ADENOID CYSTIC CARCINOMA (CYLINDROMA)
Most common malignant tumor of the submandibular glands and the second most common parotid malignancy
25-30% cn vii paralysis/paresis on presentation
Perineural invasion is commonHistologically (three types)1 cribriform 2 tubular 3 solid form
CLINICAL FEATURES
UNPREDICTABLE TUMORPain is common and important findingPain is common and important findingSLOW GROWING, HOWEVER,
RELENTLESS DISEASELUNG METASTASIS COMMONLYMPH NODE INVOLVEMENT NOT
COMMON
TREATMENT:
Surgical resection of the gland with possible nerve resection if involved
Postoperative radiotherapy5 years survival rateBy age of 20 years, only 2o% of pts are
alive Death because of local recurrence or
distant metastsisPoorest prognosis of tumor from
maxillary sinus or submandibular gland
MALIGNANT PLEOMORPHIC ADENOMA (MALIGNANT MIXED TUMOR
OR CARCINOMA EX PLEOMORPHIC ADENOMA)
Etiology: Malignant transformation of a pleomorphic adenoma
5-6th DECADEAverage duration of the lesion is
present 10 years before being diagnosed
Treatment: Glandular resection with nerve resection if involved with tumor
ACINOUS (ACINIC) CELL CARCINOMA
Low, intermediate and high gradeIntravascular extension3rd-6th decadeMetastasis to the lung and bone
(vertebrae)Treatment: glandular resectionRadiotherapy is not effectiveGood prognosis
SQUAMOUS CELL CARCINOMA
Is it a metastatic lesion?1/3 have facial nerve involvement
at the time of presentationMale > female6th decadeTotal glandular resection10 year survival: 45%
ADENOCARCINOMAIs almost a tumor of minor salivary glands65% 0ccur on hard palate or soft palateUsually fixed to the surrounding structuresMale > female3rd - 6th decade22% Facial nerve involvement at the time of
presentation.25% Metastasis at the time of presentationGlandular resection with nerve resection if
involved with tumorNeck dissectionPostoperative radiotherapy
OTHER MALIGNANT MASSES
MALIGNANT ONCOCYTOMA
CLEAR CELL CARCINOMA
COMPLICATIONS OF SURGICAL INTERVENTION
ORAL FISTULASFACIAL NERVE INJURYLOSS OF EAR SENSATIONFREY’S SYNDROME (GUSTATORY
SWEATING)SKIN NECROSIS
THANKS
