TUMORS OF THE SALIVARY GLANDS. TUMORS OF THE SALIVARY GLANDS ANATOMY n ARISE FROM THE INGROWTH OF ECTODERM n PAROTID/SUBMANDIBULAR - 6TH FETAL WEEK n

TUMORS OF THE SALIVARY TUMORS OF THE SALIVARY GLANDSGLANDS

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMYANATOMY

ARISE FROM THE INGROWTH OF ECTODERMARISE FROM THE INGROWTH OF ECTODERM

PAROTIDPAROTID//SUBMANDIBULAR SUBMANDIBULAR - - 6TH FETAL WEEK6TH FETAL WEEK

SUBLINGUAL SUBLINGUAL - - 8TH FETAL WEEK8TH FETAL WEEK

MINOR SALIVARY MINOR SALIVARY - - 3RD FETAL MONTH3RD FETAL MONTH

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - PAROTIDPAROTID

LARGEST GLANDLARGEST GLAND

BOUNDARIES ARE THE EXTERNAL AUDITORY CANAL, BOUNDARIES ARE THE EXTERNAL AUDITORY CANAL, RAMUS OF THE MANDIBLE AND MASTOID PROCESSRAMUS OF THE MANDIBLE AND MASTOID PROCESS

STENSEN’S DUCT STENSEN’S DUCT - - ANTERIOR BORDER OF THE ANTERIOR BORDER OF THE MASSETER MUSCLE THROUGH THE BUCCINATOR MASSETER MUSCLE THROUGH THE BUCCINATOR MUSCLE AND EXITS INTRAORALLY ALONG SIDE THE MUSCLE AND EXITS INTRAORALLY ALONG SIDE THE MAXILLARY SECOND MOLARMAXILLARY SECOND MOLAR..

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - PAROTIDPAROTID

GLAND IS ENCASED IN A SHEATHGLAND IS ENCASED IN A SHEATH

ARTIFICIAL DIVISION BETWEEN THE DEEP AND ARTIFICIAL DIVISION BETWEEN THE DEEP AND SUPERFICIAL LOBESUPERFICIAL LOBE..

FACIAL NERVE DIVIDES THESE “LOBESFACIAL NERVE DIVIDES THESE “LOBES””..

THE EXTERNAL NARES AND THE EXTERNAL NARES AND THE TRAGUS OF THE EARTHE TRAGUS OF THE EAR..

BETWEENBETWEEN

THE PAROTID DUCT LIES ON AN IMAGINARY LINETHE PAROTID DUCT LIES ON AN IMAGINARY LINE

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - FACIAL NERVEFACIAL NERVE

EXITS FROM THE STYLOMASTOID FORAMENEXITS FROM THE STYLOMASTOID FORAMEN..

DIVIDES INTO A TEMPOROFACIAL AND DIVIDES INTO A TEMPOROFACIAL AND CERVICOFACIAL BRANCHCERVICOFACIAL BRANCH..

FIVE GROUPS OF TERMINAL BRANCHESFIVE GROUPS OF TERMINAL BRANCHES::–TEMPORALTEMPORAL//FRONTALFRONTAL

–ZYGOMATICOZYGOMATICO--ORBITALORBITAL–BUCCALBUCCAL

–MANDIBULARMANDIBULAR–CERVICALCERVICAL

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - SUBMANDIBULAR GLANDSUBMANDIBULAR GLAND

PAIRED STRUCTURESPAIRED STRUCTURES

THE LIES ALONG THE POSTERIOR BORDER OF THE LIES ALONG THE POSTERIOR BORDER OF THE MYLOHYOID MUSCLETHE MYLOHYOID MUSCLE..

WHARTON’S DUCT WHARTON’S DUCT - - TRAVELS ALONG THE TRAVELS ALONG THE POSTERIOR BORDER OF THE MYLOHYOID POSTERIOR BORDER OF THE MYLOHYOID MUSCLE AND OPENS INTRAORALLY AT THE MUSCLE AND OPENS INTRAORALLY AT THE IPSILATERAL SUBLINGUAL PAPILLA ADJACENT TO IPSILATERAL SUBLINGUAL PAPILLA ADJACENT TO THE ANTERIOR MIDLINE ON THE FLOOR OF THE THE ANTERIOR MIDLINE ON THE FLOOR OF THE MOUTHMOUTH..

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - SUBMANDIBULAR GLANDSUBMANDIBULAR GLAND

INNERVATED BY THE LINGUAL NERVEINNERVATED BY THE LINGUAL NERVE

SYMPATHETIC PLEXUS FROM THE FACIAL ARTERYSYMPATHETIC PLEXUS FROM THE FACIAL ARTERY

PARASYMPATHETICS FROM THE SUBMANDIBULAR PARASYMPATHETICS FROM THE SUBMANDIBULAR GANGLIONGANGLION

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - SUBLINGUAL GLANDSUBLINGUAL GLAND

BOUNDARIES ON THE LINGUAL SURFACE OF THE BOUNDARIES ON THE LINGUAL SURFACE OF THE ANTEROLATERAL MANDIBLEANTEROLATERAL MANDIBLE

20DUCTS WHICH DRAIN INTO THE ANTERIOR FLOOR 20DUCTS WHICH DRAIN INTO THE ANTERIOR FLOOR OF THE MOUTHOF THE MOUTH

BARTHOLIN DUCT BARTHOLIN DUCT - - COALESCENCE OF SOME OF COALESCENCE OF SOME OF THESE DUCTS INTO A MORE DEFINED DUCTTHESE DUCTS INTO A MORE DEFINED DUCT. . BARTHOLIN’S DUCT MAY EMPTY INTO WHARTON’S BARTHOLIN’S DUCT MAY EMPTY INTO WHARTON’S DUCTDUCT..

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - SUBLINGUAL GLANDSUBLINGUAL GLAND

SYMPATHETIC PLEXUSSYMPATHETIC PLEXUS: : FROM THE SUBLINGUAL FROM THE SUBLINGUAL ARTERYARTERY

PARASYMPATHETICSPARASYMPATHETICS: : FROM THE FROM THE SUBMANDIBULAR GANGLIONSUBMANDIBULAR GANGLION

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSANATOMY ANATOMY - - MINOR SALIVARY GLANDSMINOR SALIVARY GLANDS

LOCATED ON THE LIPS, PALATE, BUCCAL LOCATED ON THE LIPS, PALATE, BUCCAL MUCOSA, TONGUE, AND FLOOR OF THE MOUTHMUCOSA, TONGUE, AND FLOOR OF THE MOUTH..

TUMORS OF THE SALIVARY GLANDSTUMORS OF THE SALIVARY GLANDSINCIDENCEINCIDENCE: : 3/100,0003/100,0003%ALL BODY TUMORS3%ALL BODY TUMORS

LOCATION OF SALIVARY GLAND TUMORSLOCATION OF SALIVARY GLAND TUMORS: : 85% 85% PAROTID, 10% SUBMANDIBULAR, 1% SUBLINGUAL, 4-PAROTID, 10% SUBMANDIBULAR, 1% SUBLINGUAL, 4-5% MINOR SALIVARY GLANDS5% MINOR SALIVARY GLANDS

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS MASSESMASSES

DIFFERENTIAL DIAGNOSIS OF A SALIVARY GLAND MASS:

–INFLAMMATION (PAROTIDITIS)–MUMPS–CALCULI

–NEOPLASM

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS BENIGN MASSESBENIGN MASSES

80%OF ALL BENIGN LESIONS ARISE IN THE 80%OF ALL BENIGN LESIONS ARISE IN THE LATERAL LATERAL ((TAILTAIL) ) OF THE PAROTID GLANDOF THE PAROTID GLAND..

SUPERFICIAL PAROTIDECTOMY WITH SUPERFICIAL PAROTIDECTOMY WITH PRESERVATION OF THE FACIAL NERVEPRESERVATION OF THE FACIAL NERVE

TOTAL SUBMANDIBULAR AND SUBLINGUAL TOTAL SUBMANDIBULAR AND SUBLINGUAL GLAND RESECTIONGLAND RESECTION


PLEOMORPHIC ADENOMAPLEOMORPHIC ADENOMA

BENIGN MIXED TUMORBENIGN MIXED TUMOR

MYOEPITHELIAL AND EPIDERMOID CELL ORIGINMYOEPITHELIAL AND EPIDERMOID CELL ORIGIN

MOST COMMON NEOPLASM IN THE PAROTID MOST COMMON NEOPLASM IN THE PAROTID GLAND ACCOUNTS FOR 65% OF ALL OF THE GLAND ACCOUNTS FOR 65% OF ALL OF THE PAROTID TUMORSPAROTID TUMORS..


PLEOMORPHIC ADENOMAPLEOMORPHIC ADENOMA

TREATMENTTREATMENT: : WIDE RESECTION OF THE TUMORWIDE RESECTION OF THE TUMOR

AVOID SHELLING OUT THE LESIONAVOID SHELLING OUT THE LESION

RECURRENCERECURRENCE: : PRIMARY DUE TO INADEQUATE PRIMARY DUE TO INADEQUATE RESECTIONRESECTION

LESIONS ARE MORE AGGRESSIVE WHEN THEY LESIONS ARE MORE AGGRESSIVE WHEN THEY RECURRECUR..


WARTHIN’S TUMOR WARTHIN’S TUMOR ((ADENOLYMPHOMAADENOLYMPHOMA))

SECOND MOST COMMON PAROTID TUMORSECOND MOST COMMON PAROTID TUMOR

MALE MALE : : FEMALE 5FEMALE 5 : : 11

BILATERAL 10%BILATERAL 10%

PRIMARILY LOCATED IN THE LATERAL GLAND HOWEVER PRIMARILY LOCATED IN THE LATERAL GLAND HOWEVER MULTICENTRICITY IS DESCRIBEDMULTICENTRICITY IS DESCRIBED..

PEA SOUP BROWN MUCOID MATERIAL ON SECTIONINGPEA SOUP BROWN MUCOID MATERIAL ON SECTIONING

TREATMENTTREATMENT: : LATERAL OR TOTAL GLANDULAR RESECTIONLATERAL OR TOTAL GLANDULAR RESECTION


WARTHIN’S TUMOR WARTHIN’S TUMOR ((ADENOLYMPHOMAADENOLYMPHOMA))

90%CURED WITH RESECTION90%CURED WITH RESECTION

10%RECUR DUE TO MULTICENTRICITY OR 10%RECUR DUE TO MULTICENTRICITY OR INADEQUATE RESECTIONINADEQUATE RESECTION..

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS BENIGN MASSESBENIGN MASSESONCOCYTOMAONCOCYTOMA

PRINCIPALLY A PAROTID GLAND TUMORPRINCIPALLY A PAROTID GLAND TUMOR

5TH DECADE5TH DECADE

PROBABLY DUE TO HYPERPLASIA FROM AGINGPROBABLY DUE TO HYPERPLASIA FROM AGING

>>1%SALIVARY GLAND TUMORS1%SALIVARY GLAND TUMORS

CYSTIC COMPONENT HAS BEEN IDENTIFIEDCYSTIC COMPONENT HAS BEEN IDENTIFIED..


BASAL CELL ADENOMABASAL CELL ADENOMA

COMMON IN THE LATERAL PAROTID AND THE COMMON IN THE LATERAL PAROTID AND THE SUBMUCOSAL GLANDS IN THE UPPER LIPSUBMUCOSAL GLANDS IN THE UPPER LIP..

TREATMENTTREATMENT: : LATERAL OR TOTAL GLANDULAR LATERAL OR TOTAL GLANDULAR RESECTIONRESECTION..

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS BENIGN MASSESBENIGN MASSESHEMANGIOMAHEMANGIOMA

50%OF ALL PAROTID TUMORS IN CHILDREN50%OF ALL PAROTID TUMORS IN CHILDREN

TREATMENTTREATMENT: : ENVOLUTION BY THE AGE OF 5 IS ENVOLUTION BY THE AGE OF 5 IS COMMONCOMMON

CN VIICN VII: : SUPERFICIAL LOCATION IN CHILDREN SUPERFICIAL LOCATION IN CHILDREN THUS OPERATIVE INTERVENTION SHOULD BE THUS OPERATIVE INTERVENTION SHOULD BE AVOIDED AND LET ENVOLUTION PROCEED AVOIDED AND LET ENVOLUTION PROCEED UNLESS THERE IS UNCONTROLLED BLEEDINGUNLESS THERE IS UNCONTROLLED BLEEDING..

STEROID THERAPYSTEROID THERAPY


LIPOMALIPOMA4%OF ALL PAROTID TUMORS4%OF ALL PAROTID TUMORS

MALE PREDOMINANCEMALE PREDOMINANCE4-5%TH DECADE4-5%TH DECADE

TREATMENTTREATMENT: : LATERAL OR TOTAL GLANDULAR LATERAL OR TOTAL GLANDULAR RESECTIONRESECTION


MYXOMAMYXOMA

SLOW GROWINGSLOW GROWING

INFILTRATIVEINFILTRATIVE

TREATMENTTREATMENT: : WIDE RESECTION OR TOTAL WIDE RESECTION OR TOTAL GLANDULAR REMOVALGLANDULAR REMOVAL

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS MALIGNANT MASSESMALIGNANT MASSES

PROGNOSISPROGNOSIS: : PALATE > PAROTID > SUBMANDIBULAR PALATE > PAROTID > SUBMANDIBULAR / / SUBLINGUAL GLANDSUBLINGUAL GLAND

5TH-6TH DECADE5TH-6TH DECADE

RATE OF GROWTH DOES NOT CORRELATE WITH THE RATE OF GROWTH DOES NOT CORRELATE WITH THE DEGREE OF MALIGNANCYDEGREE OF MALIGNANCY

LUNGLUNG//BONEBONE: : PRIMARY METASTATIC SITESPRIMARY METASTATIC SITES

PRIOR RADIOTHERAPY INCREASES THE RISK OF A PRIOR RADIOTHERAPY INCREASES THE RISK OF A SALIVARY GLAND MALIGNANCYSALIVARY GLAND MALIGNANCY..


MUCOEPIDERMOID CARCINOMAMUCOEPIDERMOID CARCINOMAMUCOUS AND EPIDERMOID CELL ORIGINMUCOUS AND EPIDERMOID CELL ORIGIN

6%OF ALL PAROTID TUMORS 6%OF ALL PAROTID TUMORS - - MOST COMMON MOST COMMON MALIGNANCYMALIGNANCY

65%FOUND IN THE PAROTID GLAND65%FOUND IN THE PAROTID GLAND18%OF ALL MALIGNANT TUMORS OF THE 18%OF ALL MALIGNANT TUMORS OF THE

SALIVARY GLANDSSALIVARY GLANDS


MUCOEPIDERMOID CARCINOMAMUCOEPIDERMOID CARCINOMA

LOW, INTERMEDIATE AND HIGH GRADESLOW, INTERMEDIATE AND HIGH GRADES

4-6TH DECADE4-6TH DECADE

8%CN VII INVOLVEMENT AT THE TIME OF 8%CN VII INVOLVEMENT AT THE TIME OF PRESENTATIONPRESENTATION

10%LYMPH NODE METASTASIS10%LYMPH NODE METASTASIS


MUCOEPIDERMOID CARCINOMAMUCOEPIDERMOID CARCINOMATREATMENTTREATMENT: : TOTAL GLANDULAR RESECTION TOTAL GLANDULAR RESECTION +/- +/-

NECK NODE DISSECTIONNECK NODE DISSECTION

CN VIICN VII: : SPARE NERVE UNLESS INVOLVED WITH SPARE NERVE UNLESS INVOLVED WITH TUMORTUMOR..

POSTOPERATIVE RADIOTHERAPY DEPENDING ON POSTOPERATIVE RADIOTHERAPY DEPENDING ON MARGINS, EXTRACAPSULAR EXTENSION FROM MARGINS, EXTRACAPSULAR EXTENSION FROM LYMPH NODES, PERINEURAL INVOLVEMENT, OR LYMPH NODES, PERINEURAL INVOLVEMENT, OR INVOLVEMENT OF SURROUNDING STRUCTURESINVOLVEMENT OF SURROUNDING STRUCTURES


MUCOEPIDERMOID CARCINOMAMUCOEPIDERMOID CARCINOMA

RECURRENCE RATE 15-25%, USUALLY DUE TO RECURRENCE RATE 15-25%, USUALLY DUE TO INADEQUATE RESECTIONINADEQUATE RESECTION..

WHEN MUCUOEPIDERMOID CARCINOMA IS WHEN MUCUOEPIDERMOID CARCINOMA IS LOCATED IN THE SUBMANDIBULAR GLAND, THE LOCATED IN THE SUBMANDIBULAR GLAND, THE TUMOR IS MORE AGGRESSIVETUMOR IS MORE AGGRESSIVE..

RARELY INVOLVES THE SUBLINGUAL GLANDRARELY INVOLVES THE SUBLINGUAL GLAND


ADENOID CYSTIC CARCINOMA ADENOID CYSTIC CARCINOMA ((CYLINDROMACYLINDROMA))

MOST COMMON MALIGNANT TUMOR OF THE MOST COMMON MALIGNANT TUMOR OF THE SUBMANDIBULAR GLANDS AND THE SECOND SUBMANDIBULAR GLANDS AND THE SECOND MOST COMMON PAROTID MALIGNANCYMOST COMMON PAROTID MALIGNANCY

25-30%CN VII PARALYSIS25-30%CN VII PARALYSIS//PARESIS ON PARESIS ON PRESENTATIONPRESENTATION

PERINEURAL INVASION IS COMMONPERINEURAL INVASION IS COMMON

GRAY PINK WITH CRIBRIFORM HISTOLOGYGRAY PINK WITH CRIBRIFORM HISTOLOGY

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS MALIGNANT MASSES MALIGNANT MASSES


UNPREDICTABLE TUMORUNPREDICTABLE TUMOR

SLOW GROWING, HOWEVER, RELENTLESS SLOW GROWING, HOWEVER, RELENTLESS DISEASEDISEASE

LUNG METASTASIS COMMONLUNG METASTASIS COMMON

LYMPH NODE INVOLVEMENT NOT COMMONLYMPH NODE INVOLVEMENT NOT COMMON



TREATMENTTREATMENT: : SURGICAL RESECTION OF THE SURGICAL RESECTION OF THE GLAND WITH POSSIBLE NERVE RESECTION IF GLAND WITH POSSIBLE NERVE RESECTION IF INVOLVEDINVOLVED

POSTOPERATIVE RADIOTHERAPYPOSTOPERATIVE RADIOTHERAPY

MALIGNANT PLEOMORPHIC ADENOMA MALIGNANT PLEOMORPHIC ADENOMA ((MALIGNANT MIXED TUMOR MALIGNANT MIXED TUMOR

OR CARCINOMA EX PLEOMORPHIC ADENOMAOR CARCINOMA EX PLEOMORPHIC ADENOMA))

ETIOLOGYETIOLOGY: : MALIGNANT TRANSFORMATION OF A MALIGNANT TRANSFORMATION OF A PLEOMORPHIC ADENOMAPLEOMORPHIC ADENOMA

5-6TH DECADE5-6TH DECADEAVERAGE DURATION OF THE LESION IS AVERAGE DURATION OF THE LESION IS

PRESENT 10 YEARS BEFORE BEING PRESENT 10 YEARS BEFORE BEING DIAGNOSEDDIAGNOSED

TREATMENTTREATMENT: : GLANDULAR RESECTION WITH GLANDULAR RESECTION WITH NERVE RESECTION IF INVOLVED WITH TUMORNERVE RESECTION IF INVOLVED WITH TUMOR

ACINOUS ACINOUS ((ACINICACINIC) ) CELL CARCINOMACELL CARCINOMA

LOW, INTERMEDIATE AND HIGH GRADELOW, INTERMEDIATE AND HIGH GRADEINTRAVASCULAR EXTENSIONINTRAVASCULAR EXTENSION

3RD-6TH DECADE3RD-6TH DECADEMETASTASIS TO THE LUNG AND BONE METASTASIS TO THE LUNG AND BONE

((VERTEBRAEVERTEBRAE))TREATMENTTREATMENT: : GLANDULAR RESECTIONGLANDULAR RESECTION

RADIOTHERAPY IS RADIOTHERAPY IS NOT NOT EFFECTIVE EFFECTIVE


SQUAMOUS CELL CARCINOMASQUAMOUS CELL CARCINOMA

IS IT A METASTATIC LESIONIS IT A METASTATIC LESION??1/3HAVE FACIAL NERVE INVOLVEMENT AT THE 1/3HAVE FACIAL NERVE INVOLVEMENT AT THE

TIME OF PRESENTATIONTIME OF PRESENTATION

MALE > FEMALEMALE > FEMALE

6TH DECADE6TH DECADETOTAL GLANDULAR RESECTIONTOTAL GLANDULAR RESECTION

10YEAR SURVIVAL10YEAR SURVIVAL: : 45%45%

ADENOCARCINOMAADENOCARCINOMA

USUALLY FIXED TO THE SURROUNDING STRUCTURESUSUALLY FIXED TO THE SURROUNDING STRUCTURESMALE > FEMALEMALE > FEMALE

3RD 3RD - - 6TH DECADE6TH DECADE22%FACIAL NERVE INVOLVEMENT AT THE TIME OF 22%FACIAL NERVE INVOLVEMENT AT THE TIME OF

PRESENTATIONPRESENTATION25%METASTASIS AT THE TIME OF PRESENTATION25%METASTASIS AT THE TIME OF PRESENTATION

GLANDULAR RESECTION WITH NERVE RESECTION IF GLANDULAR RESECTION WITH NERVE RESECTION IF INVOLVED WITH TUMORINVOLVED WITH TUMOR

NECK DISSECTIONNECK DISSECTIONPOSTOPERATIVE RADIOTHERAPYPOSTOPERATIVE RADIOTHERAPY


UNDIFFERENTIATED CARCINOMAUNDIFFERENTIATED CARCINOMA

7TH-8TH DECADE7TH-8TH DECADE33%FACIAL NERVE INVOLVEMENT AT THE TIME 33%FACIAL NERVE INVOLVEMENT AT THE TIME

OF PRESENTATIONOF PRESENTATION

HIGHLY MALIGNANTHIGHLY MALIGNANT

TREATMENTTREATMENT: : GLANDULAR RESECTION, NECK GLANDULAR RESECTION, NECK DISSECTION, POSTOPERATIVE RADIOTHERAPYDISSECTION, POSTOPERATIVE RADIOTHERAPY

NERVE RESECTION IF INVOLVEDNERVE RESECTION IF INVOLVED

TUMORS OF THE SALIVARY GLANDS TUMORS OF THE SALIVARY GLANDS COMPLICATIONS OF SURGICAL INTERVENTIONCOMPLICATIONS OF SURGICAL INTERVENTION

ORAL FISTULASORAL FISTULASFACIAL NERVE INJURYFACIAL NERVE INJURY

LOSS OF EAR SENSATIONLOSS OF EAR SENSATIONFREY’S SYNDROME FREY’S SYNDROME ((GUSTATORY SWEATINGGUSTATORY SWEATING))

SKIN NECROSISSKIN NECROSIS

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TUMORS OF THE SALIVARY GLANDS. TUMORS OF THE SALIVARY GLANDS ANATOMY n ARISE FROM THE INGROWTH OF ECTODERM n PAROTID/SUBMANDIBULAR - 6TH FETAL WEEK n