SALIVARY GLAND TUMOURS
Presenter : Dr Vamsivardhan P
Guide: Dr Ravishankar NProfessor Dept of SurgeryJss medical collegeMysuru
AETIOLOGY Genetic
loss of alleles of chromosomes in 12q, 8q, 17q. Infective
Mumps Epstein-Barr virus chronic sialadenitis: Recurrent inflammation can cause duct
dysplasia and carcinoma. Radiation
More common in survivors of atomic bomb explosion Smoking
Adenolymphoma of Warthin’s shows 40% risk in smokers Sex
Benign tumours and many malignancies are common in females Warthin’s and some malignancies are common in males.
Environment and diet Deficiency of vitamin A Industrial agents like nickel, cadmium, hair dyes, silica,
preservatives
Salivary gland tumoursEpithelial
Non Epithelial
Malignant Lymphomas
Lymphoepithelial Tumours
Secondaries
WHO classification
Epithelial tumours
Adenomas Carcinomas
Pleomorphic adenoma
Monomorphic adenomas
• Adenolymphoma (WARTHINS TUMOUR)
• Oncocytoma
• Basal cell Adenoma
Carcinoma
Low grade High grade
• Acinic cell carcinoma• Adenoid cystic
carcinoma• Low-grade
mucoepidermoid carcinoma
• Adenocarcinoma• Squamous cell carcinoma• High-grade
mucoepidermoid carcinoma
Non Epithelial
Haemangioma Lymphangioma Neurofibromas & Neurilemommas
• Common in infants• Spontaneous regression• MC benign salivary gland tumour in children
Malignant lymphomas Common in parotids. Common with
HIV Sjögren’s syndrome
Secondaries Secondary tumours from
head and neck region bronchus and skin
Lymphoepithelial tumours
Benign
Godwin’s tumour
(BLEL) Benign lymphoepithelial lesion
associated with Mikulicz’s disease or Sjögren’s syndrome
Malignant
(ESKIMOMA)Rare tumour occurs in
parotid and submandibular glands
INCIDENCE 80% per cent salivary neoplasms are in the
parotids of which 80% are benign; 80% of these are pleomorphic adenomas.
50% per cent of salivary tumours are in the submandibular salivary gland, of which 50% are benign. 95% of these are pleomorphic adenomas.
10% percent of salivary neoplasms are in the minor salivary glands : Of these only 10% are benign.
PLEOMORPHIC ADENOMA (MIXED SALIVARY TUMOUR) Commonest of the salivary gland tumour in
adult. More common in parotids (80%). 10% submandibular salivary gland 0.5% sublingual salivary gland.
Grossly it contains cartilages, cystic spaces, solid tissues.
Microscopically it is biphasic in nature with epithelial and stromal components
Common in females (3:1).
Common in 4th and 5th decade
Unilateral.
Present as a single painless, smooth, firm lobulated, mobile swelling in front of the parotid with positive curtain sing
Obliteration of retromandibular groove is common.
Capsulated, tumour may have pseudopods and may extend beyond the main limit of the tumour
Involves superficial lobe superficial and deep lobe together.
Deep lobe involvement Presents as swelling in the lateral wall of the
pharynx, soft palate and posterior pillar
Deep lobe is involvment
Commonly located in the lateral wall of pharynx, posterior pillar and over the soft palate
No visible swelling in the preauricular region.
Dumbbell tumour
passes through Patey’s stylomandibular tunnel pushing tonsils, pharynx, soft palate often without any visible swelling
Bidigital palpation of parotid is significant in such occasion with one finger inside mouth.
Facial nerve is not involved.
CLINICAL FEATURES Swelling pain ulceration dysphagia 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 If Malignant :
Facial nerve masseter skin lymph node bone
Complications Recurrence : 5-50% Malignancy
3-5% in early tumours 10% in long duration (15 or more years) tumours
Investigations FNAC CT scan (deep lobe, local extension metastasis) MRI
Long-standing pleomorphic adenoma may turn into carcinoma
Features suggesting Carcinoma Recent increase in size
Pain and nodularity Involvement of skin, ulceration Involvement of masseter
Involvement of cervical lymph nodes
Restriction of jaw movements
Involvement of facial nerve : LMN facial nerve palsy
TREATMENT Surgery :first line treatment
only superficial
lobe is involved
superficial parotidectomy
Both the
lobes involved
Total conservative parotidecto
myfacial nerve is retained
ADENOLYMPHOMA (WARTHIN’S TUMOUR)
Papillary Cystadenolymphomatosum
misnomer
Benign tumour that occurs only in parotid usually in the lower pole.
Trapping of jugular lymph sacs in parotid during developmental period.
Only superficial lobe of parotid gland involvement
May also be multicentric.
Smoking (40%/8 times more risk than nonsmokers)
Radiation exposure
CLINICAL FEATURES
Slow growing, smooth, soft, cystic, fluctuant swelling, in the lower pole Bilateral and is nontender. Common in males; 4:1. Common in smokers. Common in old people > 60 years. Incidence is 10% 2nd most common benign tumour. Often bilateral—10%.
INVESTIGATIONS Technetium99 pertechnetate scan
Adenolymphoma produces a “hot spot” diagnostic
FNAC.
Adenolymphoma does not turn into malignancy occasionally it can simultaneously be associated
with pleomorphic adenoma carcinoma lymphoma of parotid.
Treatment Superficial parotidectomy.
ONCOCYTOMA (OXYPHIL ADENOMA) < 1% of salivary tumours. Usually benign, originating from oncocytes
(oxyphilic cells) Causes.
Radiation occupational hazards
Common in parotid Rarely can occur in submandibular salivary
gland. Investigations.
99Tc with hotspots FNAC
BASAL CELL ADENOMA Rare, benign tumour Common in minor salivary glands In major salivary glands it is multicentric Grossly it looks like lymph node Microscopy : isomorphic basaloid cells with
solid/ tubular/membranous pattern
Canalicular adenoma variant with bilayered ribbons of columnar cells
separated by vascular stroma
MUCOEPIDERMOID TUMOUR
Commonest malignant tumour in parotid
2nd common malignant tumour in submandibular and sublingual salivary glands
Incidence : 9% of salivary tumours
20% of malignant salivary tumours
Occurs both in major as well as minor salivary glands.
Parotid is the commonest site
Palate is the commonest minor salivary gland site (In the palate adenoid cystic carcinoma is common).
Radiation is the commonest etiological factor.
Slowly progressive, often attains a large size and spreads to neck lymph nodes.
Contains malignant epidermoid and mucous secreting cells.
Types Low grade : mucous cells mainly , spreads to
regional nodes.
Intermediate : clear cell variety
High grade : epidermoid cells mainly : spreads to regional nodes and also shows high propensity for distant spread.
Facial nerve involvement is late
CLINICAL FEATURES Swelling in the salivary (parotid or
submandibular) region
Slow increasing in size
Attains a large size, which is hard, nodular, often with involvement of skin and lymph nodes
Common in females (3:1) , slow growing
Pain, skin and facial involvement are not common unless it is high grade
ADENOID CYSTIC CARCINOMA(10% OF SALIVARY TUMOURS)Cylidromatous carcinoma Most common tumour in Sublingual salivary glands
50% of cases occur in minor salivary glands: palate
2nd most common malignant salivary tumour
Rare in parotid (2% of parotid tumours, 15% of malignant parotid tumours
Common in females (3:2)
Common in 5th and 6th decades
Slow growing but highly malignant
Remarkable capacity for recurrence
High affinity for perineural spread
Blood spread can occur to lungs, bones and liver
Lung secondaries remain dormant not a contraindication for surgery of primary
tumour
Treatment of choice
Radical parotidectomy
radical excision of submandibular and sublingual glands with neck nodal dissection and postoperative
RT
Poor prognosis on microscopy Positive margin perineural spread solid type
Lung metastasis will not affect the prognosis.
Local recurrence is common
5-year survival is 70%.
ACINIC CELL TUMOUR Rare, slow growing tumour that occurs almost always
in parotid and is composed of cells alike serous acini.
More common in women
Occurs in adult and elderly
3% of salivary tumours : 90% occurs in parotid.
Can involve facial nerve or neck lymph nodes.
Clinically it is of variable consistency with soft and cystic areas.
low grade malignant tumour
MALIGNANT MIXED TUMOUR (MMT) 10% of salivary malignancy in incidence with
epithelial and mesenchymal elements. Carries worst prognosis.
MMT TypesCarcinoma ex pleomorphic adenoma
Primary malignant mixed tumour
Metastasizing mixed tumours
In situ non-invasive carcinoma in pleomorphic adenoma
Carcinoma ex pleomorphic adenoma: Commonest type
long standing parotid swelling shows rapid change, fixity, facial nerve spread, neck nodal involvement
Transformation is 2% in tumour of 5 years duration; 10% in 15 years tumour
Most aggressive salivary malignancy
Treatment. Radical parotidectomy
Primary malignant mixed tumour:
Also called as carcinosarcoma which arises as de novo
Shows components of both carcinoma and sarcoma with metastatic potential both through lymph nodes and blood.
Metastasizing mixed tumours:
contains structures typical of benign mixed tumour both at original and at metastases sites.
In situ non-invasive carcinoma in pleomorphic adenoma:
No evidence of capsular invasion.
Lesion with
< 8 mm invasion in depth shows 100% of 5-year survival
> 8 mm invasion carries 5-year survival < 50%.
ADENOCARCINOMA OF SALIVARY GLANDS
3% of parotid 10% of submandibular and minor salivary
gland tumours Equal in both sexes Common in children Can be
tubular papillary undifferentiated
20% involve facial nerve clinically.
Undifferentiated type is aggressive.
SQUAMOUS CELL CARCINOMA OF SALIVARY GLANDS Rare in salivary glands.
Parotid is the common site
high grade tumour
Common in men (3:1).
Occurs in 6th or 7th decade
Aggressive nonencapsulated tumour arising from ductal system grows rapidly causing pain, facial palsy, skin fixity , ulceration.
Commonly spreads to neck nodes
Poor prognosis.
Treatment Radical parotidectomy
RT
PAROTID LYMPHOMA Occur from the lymph nodes in the gland or
from parotid parenchyma.
Occur HIV patients lymphoepithelial diseases Sjögren’s syndrome.
Common in elderly.
Confined to parotid gland or may involve other nodes in neck, mediastinum.
Confined to parotid Total parotidectomy with radiotherapy and later
chemotherapy is the treatment.
Multiple lymphnodes are involved chemotherapy is the choice therapy
SUBMANDIBULAR SALIVARY GLAND TUMOURSBenign tumours: 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.
Malignant tumours of submandibular salivary gland:
hard, nodular
fixed to skin muscles hypoglossal nerve mandible
Diagnosis is by FNAC of primary tumour and of lymph nodes when involved
CT scan
MANAGEMENT
Excision of the gland
Lymph nodes are involved block dissection of neck Classical neck dissection is done
MINOR SALIVARY GLAND TUMOURS 10% of salivary tumours.
common in palate (40%). lip. cheek. sublingual glands.
10% are benign : commonly pleomorphic adenomas.
90% are malignant : commonly adenoid cystic carcinomas.
Present as swelling with ulcer over the summit.
Malignant extends into the palate, maxilla, pterygoids can
occur often with involvement of the lymph node
Differential Diagnosis Squamous cell carcinoma of oral cavity.
Investigations Incision biopsy. CT scan. X-ray maxilla. FNAC of lymph node
MANAGEMENT
Malignancy Wide excision often with palatal excision or
maxillectomy is done Tumour < 1 cm in size :
Excision biopsy is done with 1 cm clearance margin.
Tumour > 1 cm in size : Initially incision biopsy is done and then wide excision is done.
Bony palate is infiltrated that part of palate bone is removed area is reconstructed Reconstruction by dental plates, skin grafting, or
flaps are done.
Lymphnode block dissection of the neck is done if cervical lymphnodes involved.
benign tumours Excision with primary closure is done
SPECIFIC INVESTIGATIONS
FNAC
Confirms possibility Lymphoma/inflammatory masses.
Allows preoperative assesment ofNature of tumourExtent of resection (conservative/radical)Management of facial nerve (high grade
adenoid cystic)Likelihood of neck dissection (high grade).
CT scan Deep lobe involvement Involvement of bone Extension into the base of theskull Relation of tumour to internal carotid artery, styloid process, deep lobe tumour, parapharyngeal space extension Neck nodes are better assessed Bony changes in the foramina, erosions and
sclerotic margins in fissures or canals, enlarged diameter of canal and fissure are the CT features of perineural spread.
MRI
Find out perineural spread
Bone marrow involvement, skull bones, internal architecture and intracranial extensions, recurrent tumours
Replacement of perineural fat with tumour, contrast (gadolinium) enhancement, increased size of the nerve are features of perineural spread
GENERAL FEATURES OF MALIGNANT SALIVARY TUMOURS Fixation
Resorption of adjacent bone
Pain and anaesthesia in the skin and mucosa
Muscle paralysis
Skin involvement and nodularity
Involvement of jaw and masticatory muscle
Nerve involvement
Blood spread when occurs, commonly to lungs
Mandibular branch of 5th cranial nerve involved
TNM Staging of Malignant Salivary Tumours
T: Tumour Tx : Tumour cannot be assessed. T0 : No evidence of primary tumour. T1 : Tumour < 2cm without extraparenchymal spread. T2 : Tumour 2-4 cm, without extraparenchymal extension T3 : Tumour >4 cm. or with extraparenchymal spread. but no facial nerve spread. T4 : T4a :Spread to facial nerve, skin, mandible, ear canal T4b :spread to base of skull, pterygoid plates, encased external carotid artery
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
STAGING
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III T3 N0/N1 Mo
Stage IVA T4a N2N1N0 M0
Stage IVB T4b any NM0; any T N3M0
Stage IVC Any T any N M1
SURGICAL MANAGEMENT Indications for surgery
T1, T2, T3 tumours of low grade
Total conservative parotidectomy
T4 tumourshigh grade tumours
SCC
Radical parotidectomy
PAROTIDECTOMYtypes
Superficial parotidectomy
Total conservative parotidectomy
Suprafacial parotidectomy
Radical parotidectomy
Superficial parotidectomy:
Removal of superficial lobe of the parotid (superficial to facial nerve)
Done in case of benign diseases of superficial lobe of the parotid. Ex: Pleomorphic Adenoma
Lazy ‘S’ incision—modifi ed Blair's/Sistrunk's approach and raising the skin flaps
Mobilisation of the gland Flap is reflected in front just up to anterior
margin of the parotid
After identification of sternocleidomastoid great auricular nerve is identified and can be sacrificed
Posterior belly of digastric is identified.
Location of stylomastoid branch of posterior auricular artery is anterior to facial nerve trunk which enters the stylomastoid foramen.
Identification of facial nerve trunk Dissection of the gland off the facial nerve
using bipolar cautery
Removal of parotid—superficial
Distilled water (hypertonic) irrigation to kill spilled tumour cells
Haemostasis and closure with a suction drain
Total conservative parotidectomy Done in benign diseases of parotid involving
either only deep lobe or both superficial and deep lobes
Both lobes are removed
Preservation of facial nerveInitially superficial parotidectomy is done
Facial nerve and its branches are retracted
Deep lobe is removed
Deeper part of the deep lobe is dissected of the stylopharyngeus and stylohyoid muscles by blunt dissection while retracting the deep lobe
Deep lobe can be dissected out superior/inferior/in between nerve branches.
Haemostasis should be achieved using bipolar cautery.
Main trunk of the facial nerve is stimulated with 0.5 mA to confirm the anatomical and physiological integrity of the branches of the facial nerve
RADICAL PAROTIDECTOMY
Removal of Both lobes of parotid Facial nerve Mandibular ramus Masseter muscle Infratemporal fossa dissection Subtotal petrosectomy
Indications for facial nerve sacrifice
Preoperative weakness/paralysis of nerve
Intraoperative evidence of gross invasion even in presence of normal preoperative function
Tumour involvement through facial nerve from superficial to deep lobe
Positive frozen section of nerve stump mastoidectomy and nerve dissection in temporal
bone is done
Facial nerve is reconstructed Greater auricular nerve Sural nerve
All branches except buccal branch are repaired using cable graft
Nerve graft is not a contraindication for future RT
Radical neck dissection
If Lymph nodes are involved, which is confirmed by FNAC is done
Done in N0 with high-grade tumour or T3/T4 tumours
Suprafacial parotidectomy
Done in lower pole parotid tumours where in all branches of the facial nerve need not be dissected
RADIOTHERAPY Given in 3-6 weeks after surgery Dose is 50-70 Gy (1.5- 2.0 Gy in 5-8 weeks)
Indications T3, T4 tumours High grade tumours Perineural spread Adenoid cystic carcinomas Deep lobe tumour Vascular involvement Close clearance margin Multiple neck nodes involvement Recurrent malignant tumours Recurrent pleomorphic adenoma Spillage after surgery for pleomorphic adenoma Residual/refractory tumours/nerve involvement
Preoperative radiotherapy
Given in large tumours to reduce the size and make it better operable, i.e. to down stage the disease
Postoperative radiotherapy
Useful to reduce the chances of relapse
External radio therapy is given
Given in all carcinomas
More useful in Adenoid cystic and Squamous cell carcinomas
COMPLICATIONS OF PAROTIDECTOMY Facial nerve injury Haemorrhage Salivary fistulas
Infection : Flap necrosis is common
Frey’s syndrome
Sialocele Numbness over the face and ear - due to injury to
great auricular nerve Spontaneous recovery may occur in 1½ to 2 years
FREY’S SYNDROME Auriculotemporal SyndromeGustatory Sweating Occurs in 10% of cases. Injury to the auriculotemporal nerve
Inappropriate regeneration of the damaged
parasympathetic autonomic nerve fibers to the overlying skin
post-ganglionic parasympathetic fibres from the
otic ganglion
sympathetic nerves from the
superior cervical
ganglion
united
Auriculotemporal nerve has got two branches.
Auricular branch supplies external acoustic meatus, surface of tympanic membrane, skin of auricle above external acoustic meatus
Temporal branch supplies hairy skin of the temple.
Sweating and hyperaesthesia occurs in this area of skin
Causes
Surgeries or accidental injuries to the parotid.
Surgeries or accidental injuries to temporoman dibular joint
Clinical Features Flushing, sweating, erythema, pain and
hyperaesthesia in the skin over the face innervated by the auriculotemporal nerve, whenever salivation is stimulated (i.e. during mastication).
Starch iodine test Involved skin is painted with iodine and driedDry starch applied over this area will become
blue due to more sweat in the area in Frey’s syndrome
Treatment Initially conservative and reassurance
Most often they recover without any active treatment in 6 months
Antiperspirants : aluminium chloride
Anticholinergics like scopolamine 3%, glycopyrrolate 1%, methyl sulfate, radiation 50 Gy are used
Injection of botulinum toxin to the affected skin
Prevented on table by placing muscle (sternomastoid) or fascial (temporalis) flaps or artificial membranes over parotid bed, under the skin
Jacobsen nerve neurectomy: 10% require surgical division of the tympanic
branch of the glossopharyngeal nerve below the round window of middle ear
MANAGEMENT OF SUBMANDIBULAR GLAND TUMOURS Surgical excision is the goal. Intracapsular submandibular gland excision
Tumour is small and entirely encased within the submandibular gland parenchyma, straightforward is appropriate.
Suprahyoid neck dissection benign tumours that are large and project
beyond the submandibular gland Neck dissection or radical neck dissection is
appropriate malignancy
SUPRAOMOHYOID NECK DISSECTION En bloc removal of cervical lymph node groups I-
III
Posterior limit is the cervical plexus and posterior border of the SCM
Inferior limit is the omohyoid muscle overlying the IJV
EXCISION OF THE SUBMANDIBULAR SALIVARY GLAND Neck extended with chin towards opposite
side Incision is made 2-4 cm below and parallel to
margin of the mandible of 6-8 cm in length
Marginal mandibular nervesubplatysmal plane in neckavoid injury to this nerve
Superficial lobe of the glandexposed fully in digastric triangle between
two bellies of digastric and stylohyoid muscles below
Dissection begins at the lower end of the gland by incising the fascia just above the digastric muscle.
Superficial lobe of the gland is mobilised upwards Hypoglossal nerve at lower part very close to the
digastric tendon which is identified and safeguarded
Mylohyoid muscle is retracted so as to remove the deep portion of the gland which is in front of the hyoglossus and mylohyoid
Submandibular ganglion is often seen just above the gland which can be sacrificed.
Wharton’s duct identification and ligation is done
RADICAL EXCISION OF SUBMANDIBULAR SALIVARY GLAND Done in malignant tumours of the
submandibular salivary glan
Nerves are sacrificed if infiltrated
Marginal mandibular nerve Difficult to retain for oncological clearance
Radical neck lymph node dissection is also usually done
CONCLUSION 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 CT scan or MRI are often needed Nerve should be preserved in benign lesions Nerve can be sacrificed to achieve clearance
in malignancies
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