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Salivary Gland Tumors
Marka Crittenden M.D. Ph.D.
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Anatomy
Major Glands
Parotid, submandibular and sublingual glands
Minor Glands Hundreds residing in the oral cavity, pharynx and
paranasal sinuses.
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?
Major Salivary Glands
?
?
?
?
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Parotid Gland
Borders
Superior zygomatic arch.
Posterior angle of mandible under earlobe toward the mastoid tip.
Inferior extends to the inferior aspect of the angle of mandibletoward hyoid bone.
Medial borders of the parapharyngeal-base of skull.
Lateral below the skin of the preauricular cheek-upper neck.
Anterior wraps around ascending ramus of mandible
Facial nerve divides the gland into the superficial (80 %) and deeplobe (20%)
Parotid duct (Stensons) is 5 cm long and opens opposite the secondmolar.
Lymphatic drainage periparotid/intraparotid lvl I lvl II- lvl III.
Accessory parotid lobe Present in 20% of patients.
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Submandibular Gland
Borders Lateral proximal half of the mandible.
Posterior anterior to but near the low anterior margin of theparotid gland.
Inferior approaches the level of the hyoid bone.
Majority of gland lies over the external surface of the mylohyoidmuscle.
Lateral to and abuts the lingual and hypoglossal nerve and ismedial to the marginal mandibular and cervical branch of thefacial nerve.
Drains through Whartons duct in anterior floor of themouth
Lymphatic Drainage Lvl I Lvl II- Lvl III
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Sublingual Gland
10% size of parotid gland
Located anterior floor of the mouth
Borders Lateral medial aspect of mandible Inferior mylohyoid muscle
Lingual nerve courses adjacent to sublingualgland
Drain into the floor of the mouth through Rivinusducts
Lymphatic drainage Lvl I- Lvl II- Lvl III
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Epidemiology
Salivary tumors 7% of head and neck tumors
Parotid tumors 10x more common then submandibularand 100x more common then lingual
Parotid 80% benign (pleomorphic adenoma) Submandibular 50% malignant
Sublingual majority (65-88%) are malignant
Equal incidence between sexes
Risk Factors: nutritional deficiency, exposure to ionizingradiation, UV exposure, genetic predisposition, EBV
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Adenoid Cystic
Cribiform pattern differentiated
Cribiform/solid pattern moderately
differentiated Solid Features undifferentiated
Natural history ranges from months to greater
then 20 years. Lymph Node spread
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Adenoid Cystic
Perineural spread common and can track
along the cranial nerves back to the base of
skull
40% develop pulmonary mets but survival of
10-20 years can occur with pulmonary mets so
primary must be managed
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Metastatic Disease involving Parotid
Mechanism
Lymphatic spread most common from skin
Hematogenous spread - lung Direct extension skin or osseous sarcomas
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Staging
T1 2cm and no extraparenchymal extension
T2 > 2cm but not >4cm without
extraparenchymal extension T3 >4cm and or extraparenchymal extension
T4a invades skin, mandible, ear canal and/or
facial nerve T4b invades skull base and or pterygoid plates
and or encases carotid artery
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Parotid Tumors
Clinical presentation
Asymptomatic mass
Cranial nerve palsey inability to move one side of
face, one shoulder, one side of tongue. Evaluation
Trismus to evaluate pterygoid involvement
CT/MRI
FNA in parotid tumors 90% sensitive and >95%specific
Never perform incisional or excisional biopsy
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Parotid Tumors
Lymph Nodes Rare in adenoid cystic
12% positive in clinically negative tumors. Size and grade are risk factors
>4 cm 20% occult mets vs 4% in smaller tumor
High grade 49% risk regardless of histologic type vs 7% for low orintermediate
Distant Spread Lung
25-35% risk for mucoepidermoid, adenoid cystic andmalignant mixed tumors.
Routine CXR
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Postoperative Radiation versus Surgery for Salivary
Gland Tumors: Results from the literature
SeriesSeries ##PTsPTs
FUPFUPlengthlength(y)(y)
PrognasticPrognasticfactorsfactors
LC 5yLC 5y
SS SS/R/R
SurvSurv 5y5y
SS SS/R/R
MSKCCMSKCC 9292 S 10.5S 10.5
S/R 5.8S/R 5.8
Stage I/IIStage I/II
Stage III/IVStage III/IVPositive nodesPositive nodes
HighHigh--GradeGrade
79 9179 91
17 5117 5140 6940 69
44 6344 63
96 8296 82
9.5 519.5 5119 4919 49
28 5728 57
JHJH 8787 All patients All patients 58 9258 92 59 7559 75
MDACCMDACC 155155 7.57.5 All patients All patients 58 8658 86 5050--56 6656 66--7272
PMHPMH 271271 1010 All patientsAll patients -- 29 6829 68(RFS)(RFS)
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Submandibular tumor
Clinical presentation Asymptomatic mass
Painful mass as enlarges
Cranial nerve palsey decrease sensation in ipsilateral lower
teeth, lip and gums, inability to move ipsilateral oral tongue orinbality to move part of face.
Evaluation CT/MRI help to distinguish a pseudomass
FNA in submandibular tumors useful only if reveals amalignancy.
All lesions approached with a submandibular triangle dissection
Almost never perform incisional or excisional biopsy.
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Submandibular Tumors
Lymph Nodes
28% risk in submandibular tumors
Lvl I, II and III most common sites
Distant Spread
Lung >bone and liver
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Sublingual Tumors
Clinical presentation
Asymptomatic swelling in floor of mouth
Cranial nerve palsey ipsilateral loss of sensation
of one side of tongue.
Evaluation
CT/MRI
Most tumors are malignant so FNA only useful ifmaligant
Always resect with a formal cancer surgery
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Sublingual Tumors
Lymph Nodes
Higher risk of LN spread then parotid tumors
Lvl I is first site of drainage
Distant Spread
Lung > bones and liver
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Treatment
Surgery -Parotid 90% confined to superficial lobe perform superficial
parotidectomy
If adjacent to deep lobe - total parotidectomy
If invades adjacent soft tissue radical parotidectomy
Never perform piecemeal excision in an attempt to preservefacial nerve
Nerve grafting can be performed and RT can start3-4 wkpost op without adverse affects
Freys syndrome (gustatory sweating) due to redirection ofparasympathetic and sympathetic nerve fibers to the dermalsweat glands
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Treatment
Surgery - Submandibular
Small tumor gland excision
ECE En bloc resection with extended supraomohyoid
neck dissection
Surgery Sublingual
Small and localized can resect without
submandibular gland Generally requires resection of submandibular
gland as well.
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Treatment
Radiation Surgically unresectable tumors
EBRT with photon and or electrons with
conventional or altered fractionation
Brachytherapy EBRT
Neutron therapy
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Treatment
Radiation Surgically unresectable tumors
EBRT
Equivalent control rates as for equivalent head and
neck squamous cell cancers
Early stage 71-100% control rates
Late and Recurrent 50-70%
Hyperfractionation
Wang and Goodman reported on 14 patients using 1.6 Gy bidto 65-70 Gy.
5 yr LCR 82%
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Treatment
Radiation Surgically unresectable tumors
Brachytherapy
Used frequently with recurrent or advanced disease
5 yr LCR 60% Neutron therapy
Biologic effect of neutrons less effected by hypoxia
Lethal effects less dependent on cell cycle
Repair of sublethal damage in malignant cells is less
RBE > 2.6
Severe late effect greater 17% versus 7%
Improved local control but no diff in overall survival
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Treatment
Postoperative Radiation Indications
Close surgical margins (deep lobe parotid tumors, facialnerve sparing)
Microscopically positive margin High grade including adenoid cystic
Involvement of skin, bone, nerve (gross or extensiveperineural invasion), tumor extension beyond capsule withperiglandular and soft tissue invasion
LN spread Large tumors requiring radical resection
Tumor spillage
Recurrence
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Treatment
Postoperative Radiation
LCR with surgery and post op RT
T1 100% T2 83% T3 80% T4 43%
Technique
Parotid
Electrons lateral en face
Mixed beam 50-80% electron weighting lateral enface or wedge pair.
Photons - wedge pair or IMRT
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Treatment
Technique
Portal margins Parotid
Superior top of zygomatic bone
Inferior hyoid bone thyroid notch
Anterior - 2cm ant to upper second molar
Posterior posterior to mastoid tip.
Lateral - 2 cm flash on cheek
Medial 2 cm medial from ipsilateral oropharyngeal area. Electron portal margins are 1 cm greater
Usually 12 MeV- 16 MeV energy used
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Treatment
Technique
Portal margins Submandibular
Superior 1cm above upper border of tongue
Inferior Hyoid bone-thyroid notch interspace
Anterior anterior aspect of mental symphysis
Posterior BOT- jugulodigastric nodal area
Lateral 2 cm flash of ipsilateral mandible
Medial midline of tongue
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Treatment
Technique
Portal margins Sublingual
Superior 1cm above upper border of tongue
Inferior Hyoid bone-thyroid notch interspace
Anterior anterior aspect of mental symphysis
Posterior posterior aspect of the ascending
mandibular ramus
Lateral 2 cm flash of ipsilateral mandible
Medial 2cm past midline
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Treatment
Dosage Primary treatment
Accelerated fractionation with a delayed
concomitant boost
Phase I 1.8Gy daily to 36 Gy
Phase II 1.8 Gy as in phase I in AM x 10 fractions to
54Gy and > 6hrs 1.6 Gy to GTVx 10 fractions to 16 Gy
Spinal cord dose < 45 Gy.
IMRT to 70 Gy for GTV 63 Gy CTV 1 and 56 Gy
CTV2
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Treatment
Dosage Post op treatment
Administered within 6 weeks of surgery
High Risk 2.0 Gy/fx to 60Gy and 1.8Gy/fx to 63Gy.
Small volume known microscopic disease 66 Gy.
Elective at risk 50 Gy (2.0Gy/fx) 54 Gy(1.8Gy/fx)
Gross residual 70Gy.
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Side effects
Salivary fxn
80% of saliva produced by major salivary glands
Loss of salivary fxn complete >35 Gy
Dose limit to spare salivary function is 26 Gy.
Trismus
TMJ and masseter muscle < 50Gy. PT during and
after treatment
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Adenoid Cystic Carcinoma
Post op RT always recommended
Post op RT of entire pathway of adjacent
cranial nerve to base of skull alwaysrecommended
Regional LN spread is 15% and elective nodal
irradiation is not standard
Surgery alone LCR 25-40% +RT 75%-80%
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Pleomorphic Adenoma
Benign tumor 75% of all parotid epithelialtumors.
Surgery is treament of choice
Multiply recurrent tumors can be treated with RT >3 local recurrences
Large lesion with surgically inadequite margin
Microscopically positive surgical margins
Macroscopic residual disease Malignant transformation
50-60 Gy dose
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Minor Salivary Tumors
Highest concentrations of the glands in theoral cavity, palate, nasal cavity and paranasalsinus
500-700 Glands
No glands located in the gingiva or anteriorhalf of the hard palate
50% malignant Adenoid cystic is most common malignant
histology seen.
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Quiz
What is the most common tumor of minor
salivary glands
A. Pleiomorphic Adenoma
B. Adenoid cystic carcinoma
C. Mucoepidermoid carcinoma
D. Squamous cell carcinoma
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Quiz
What are the borders of the parotid
gland?
Superior
Inferior
Anterior
Posterior
Zyogomatic arch
Hyoid bone
Ascending ramus of
mandible
Mastoid process
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Quiz
The most common parotid tumor is
A. Pleomorphic adenoma
B. Mucoepidermoid carcinoma
C. Adenoid cystic carcinoma
D. Detroit tigers
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Quiz
Most parotid tumors are ___________
A. Benign 60%
B. Benign 80%
C. Malignant 60%
D. Malignant 80%
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Quiz
All of the following are true regarding adenoid
cystic carcinoma except?
A. It rarely spreads to Lymph nodes
B. It is a common minor salivary tumor
C. It typically does not involve nerves
D. 40% develop pulmonary metastasis
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Quiz
Adenoid cystic of parotid s/p parotidectomy
with perineural invasion, what is treatment
field?
A. Post op bed
B. Post op bed and BOS
C. Post op bed and BOS and ipsilateral neck
D. Post op bed and BOS and bilat neck
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Quiz
What is treatment of choice for cystic
pleomorphic adenoma? After rupture or
residual?
Superficial parotidectomy. If intraop cystic
rupture, add post op RT
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Quiz
How are parotid tumors staged?
T1
T2
T3
T4
2cm
2-4 cm
Extraparenchymal, No
VII involvement 4-6cm
>6cm, BOS, CN VII
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Quiz
All of the following are indication for RT in
pleiomorphic adenoma except?
A. Deep lobe involvement
B. Large >5cm
C. Recurrent tumor
D. Positive margin
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Quiz
What seperates the superficial parotid from
the deep lobe?
Facial Nerve
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Quiz
Intraparotid lymph node and a single 3cm
neck node what is the most likely primary?
Skin
Parotid
i
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Quiz
True/False series. Indication for post-
op RT for parotid tumors Close but clear margin
on benign pleomorphic
adenoma < 3cm
Adenoid cystic with clear
margin
High grade
mucopidermoid
CN VII sacrifice for tumor
close to nerve but not
invading nerve
False
True
True
False
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