Salivary Gland Tumors

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Salivary Gland Tumors

• Professor Ravi Kant
• MS, FRCS (Edin), FRCS (Glasg), FRCS (Ireland),
  DNB, FACS, FICS, FAIS, FAMS

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Objectives

• Setting CME
• Audience PG
• Time duration 20 minutes
• Evidence based

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Objectives

• Why
• How to diagnose
• The Natural Course of disease
• What treatment to offer
• Prognosis
• Limitations

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Etiology-1

• Epstein - Barr Virus
• Childhood Irradiation
• Nutritional deficiencies
• UV Exposure
• Genetic

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Etiology-2

• Wood silica dust exposure
• Kerosene users
• HIV-BLL
• Benign Lymphoepithelial lesion
• HIV-NHL, Kaposis, Ad Cy,
• Protection dark yellow vegetables liver

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 Familial occurrence of acinic cell carcinoma of
the parotid gland.

• 13 Arch Pathol Lab Med 1999 Nov123(11)1118-20
• Depowski PL, USA.

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Epstein-Barr virus infection in salivary gland
tumors in children and young adults. 

• Cancer 2000 Jul 1589(2)463-6 
• Venkateswaran L,
• Department of Hematology-Oncology, St. Jude
  Children's Research Hospital,Memphis, Tennessee,
  USA.

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Signs of malignancy-1

• Painless mass
• Nerve involvement
• Dysphagia
• Skin ulceration
• Sudden increase in size

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Signs of malignancy-2

• Symptoms of surrounding structure involvement
• Mild intermittent pain
• Numbness- mucosal, tongue, 7 n,
• 9,10,11,12 cranial nerve

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DD-deep lobe

• Oral neoplasm
• (/- fat plane on CT or MR)
• Parapharyngeal neoplasm
• Lymphoma
• Neurogenic tumor
• Paraganglioma

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Investigations

• FNAC gt90 specificity, sensitivity
• MR ideal for deep lobe
• MR Angio
• CT-3D sialography
• 99 m Tc scan for Warthins, Oncocytoma, Acinic,
  Adeno

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Investigations

• SPECT / FDG PET for No Neck
• ICA balloon occlusion testXeCT
• Frozen section biopsy 95v
• Perineural invasion
• LN mets
• Surgical margins
• Type of CA or benign 67v

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MRgtCT

• Tumor-salivary gland interface
• Benign Vs malignant
• 7 n or Perineural evaluation
• Intracranial extension of tumor
• DD Parapharyngeal tumors
• DD Neurogenic tumors

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MRgtCT Perineural spread

1. Replacement of normal perineural fat with tumor
2. Enhancement with gadolinium
3. Increased size of nerve
4. Bony erosion
5. Sclerotic margins
6. Widening of crania base channels

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CTgtMR for bone erosion

• CE-CT is better than non CE
• Base of skull involvement
• Mandible erosion

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New strategy for the diagnosis of parotid gland
lesions utilizing 3D sialography.

• Comput Aided Surg 20005(1)42-5  
• Kosaka M, Kamiishi H, Japan.

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3D sialographyadvantages-1

• (1) The structure of the acinar surface is
  visualized in detail.
• (2) The 3D structure of the entire parotid system
  from Stensen's duct to the gland is shown in one
  image.

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3D sialographyadvantages-2

• (3)The parotid gland can be assessed in the
  context of the bony architecture of facial bones.
• (4) The surface structure of the parotid gland
  can be understood very easily, like a scanning
  electron micrograph.

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BLL

• Sjogrens
• Mikulicz
• HIV asso. Malignancy K,NHL,AC
• Observe as benign
• Low dose RT
• Parotidectomy as assoc malignancy

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Warthins Papillary cyst Adenolymphoma

• Benign
• Kerala coast
• Favour tail of parotid
• 10 bilateral
• Hot on isotope scan
• Older man, bilateral, left alone

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Pleomorphic components

• Myxoid
• Mucoid
• Chondroid
• Epithelial
• Other

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Proliferative activity in recurrent pleomorphic
adenoma

• MIB1 antibody against the cell proliferation
  associated nuclear antigen (Ki-67 antigen).
• The proliferation index (MIB1 positive cells per
  100 cells)

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Proliferative activity in recurrent pleomorphic
adenoma

• Epithelial differentiation as a possible origin
  for recurrence.
• Bankamp DG Laryngorhinootologie 1999
  Feb78(2)77-80 

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Proliferative activity in recurrent pleomorphic
adenoma

• Tongue like projections,
• Pseudocapsule
• 7 n palsy
• Skull base involvement
• Locally invasive
• Recurrence even multiple

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Pleomorphic adenoma

• Malignant transformation
• Locally dangerous
• No enucleation,
• only
• Wide margin of tissue
• Superficial parotidectomy

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Pleomorphic adenoma Adjuvant RT

• Spill
• Residual
• Recurrent,
• Nerve encasing
• Deep lobe involvement
• Rx?Postoperative Radiotherapy

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T

• T1 lt2 cm
• T2 gt2-4 cm
• T3 gt4-6 cm
• T4 gt6 cm

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N

• No
• N1 lt3 cm,ipsilateral single
• N2 A gt3-6 cm,ipsilateral single
• B lt6cm,ipsilateral multiple C lt6cm,
  bilateral
• N3 gt6 cm

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LN

• Preauricular-
• Squamous
• Melanoma
• Not parotid
• Intraparotid

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M

• Mo -distant mets
• M1 distant mets

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M

• Lung
• 40 Adenoid Cystic
• 30 Malignant Mixed
• Also with Acinic cell
• SMP21
• Lung mets In AdCy can live up to 20 years

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Mode of Spread

• Expansion
• Local infiltration
• Lymphatics
• Perineural infiltration
• Seedling in the tumor and skin

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Probability of cancer
Sublingual Highest 4
Minor salivary Next Highest 3
Submandibular Next highest 2
Parotid Lowest 1
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HP Site
Histology Parotid Submandibular
Acinic 11 17
ME 32 12
Adeno 16 02
Malig. mixed 14 10
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HP Site
Histology Parotid Submand.
Adenoid Cystic 11 41
Squamous 8 9
Undifferentiated 8 9
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Acinic-1

• 16 of Parotid
• of all acinic 81 in Parotid
• 3 of all salivary
• 5th decade
• Bilateral
• More in Females

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Acinic-2

• Types- four types
• 1. Solid, 2. Microcytic, 3. Papillary-cystic,
  4. follicular
• Papillary cystic 100 mortality
• Solid has equally worse prognosis
• Node , Nerve, Margin ,T3-T4
• poor prognosis

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Acinic-3

• 5,10,15 yr survival in 100,87,65
• Local recurrence 15
• Distant Mets 10
• Facial palsy 0-8
• Regional N0-16
• Adjuvant RT in T3,T4, N
• Improper Rx recurrence rate 75, N 25

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Adenoid Cystic-1

• Billroth 1854 Cylindroma
• Minor 31, Submand 41
• Perineural invasion in 80, ? if gt1cm
• Types Tubular, Cribriform and Solid
• Solid has worst prognosis,
• High grade or low grade
• 10 yr survival in high grade is 0

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Adenoid Cystic-2

• Prognosis- T, Bone invasion, Nerve, Grade,DNA
  ploidy, best with tubular
• LN is rare lt8, lethal 6 _at_10 yr
• No role of elective neck dissection
• Site 10 yr survival
• 29 parotid, 7 paranasal

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Adenoid Cystic-3

• Adj RT for local control as recurrence 37
• No solution to distal mets 40, up to 20 years
• Mets to lung 63, Bone liver
• Survival _at_ 5y 69, _at_ 20y22 even in favorable
  grade
• 1/3 free,1/3 dead,1/3 recurrence

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Muco epidermoid

• Gr 1 Well differentiated
• Gr 2 Moderate
• Gr 3 Poorly
• Grade Low or High
• Death in 5y LGME 6, HGME 65
• Agnor count ? prognosis

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Malignant mixed-1

• 4 CA Ex pleomorphic epithelial
• Risk 1.5 lt5y long, 9.5 after 15 y
• Risk 7 with recurrent Pleomorphic
• Risk if 20y long, gt2cm, age, deep lobe, solitary
  nodule, previous surg
• de-novo carcinosarcoma, 5y 0 S

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Malignant mixed-2

• lt 8mm invasion, 5y survival 100
• gt 8mm invasion, 5y survival lt50
• Survival 5y40,10y24,15y19
• Regional mets 25Distant mets 33
• Types1. CA ex pleo2. CASA, 3.Metastasizing
  mixed, 4. Non-invasive

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Large Tumors General Principle

• Failure at distant site
• Role of Postoperative RT
• Avoid Marked mutilation
• Physiological compromise
• Lung mets not preclude rx of primary

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Rx

• Superficial / Total parotidectomy
• Save 7th Nerve,
• if not directly involved ?
• 56 recurrence even if nerve excised
• Submandibular triangle resection

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LN
Salivary CA 14
Low grade ME 2
High grade ME 44
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LN in Clinical No
Clinical No neck? Surg
High grade 49
Low grade 7
Epidermoid 41
All other 10
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LN in Clinical No
T1 7
T2 7
T3 16
T4 24
50
LN in Clinical No
Clinical No neck? Surg
Submandibular 21
Parotid 9
Ectopic 10
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SOHD of Neck- Indications

• T4 20 vs 4
• T3 16 vs 4
• High grade ME 49 vs 7
• Epidermoid 41 vs 7
• Skip 25 L3 or 4 but L2-
• Submandibular 21 vs 9 in P

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VII nerve

• Neuropraxia up to 6 months
• Interposition of
• Great auricular
• Sural

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VII nerve

• Fascia lata sling
• Muscle transfer
• Lateral tarsorrhaphy

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Adjuvant RT in high grade, LN, Stage III or IV
Study -RT RT
5 yr survival 28 57
5 yr local control 44 63
margin 54 14
Low grade tumor No benefit No benefit
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Indication for Adjuvant RT-1

• In benign
• Spill
• Residual
• Recurrent,
• Nerve encasing
• Deep lobe involvement
• After excision of residual tumor

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Indication for Adjuvant RT In malignant

1. Recurrent
2. Residual, positive margin,
3. Narrow margin on facial nerve
4. Multiple nodal involvement
5. Perineural invasion
6. High grade locally aggressive

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Indication for adjuvant RT-3

• All submandibular tumors
• -except T1,T2, Acinic or LGME
• All adenoid cystic tumors
• All T3, T4,
• All N

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Adjuvant RT

• Wedged photon pair
• Mixed plan Ipsilateral photon Electron beam
• Fast Neutron therapy
• Brachy therapy

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Adjuvant RT Choice is Fast neutron therapy

• 67 Vs 26 rr with photon or electron.
• 2 yr survival 55 vs 13
• Therapy of choice in inoperable, recurrent, or
  residual
• More toxic
• Failure due to distant mets 20 vs. loco regional
  failure in photon

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Survival 5year
Parotid 50-81
Submandibular 30-50
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Histology Survival
Tumor 5 yr 10 yr 15 yr
Acinic 75 65 44
Low grade ME 70-95 50
High grade ME 30-50
Adenoid cystic 50-90 30-67 25
Adeno 76-85 34-71
Malig. mixed 31-65 24 19
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Summary

• P/E Mucosal numbness
• FNAC MR 3D CT
• No role of enucleation in benign- Minimum is supf
  parotidectomy
• RND in HGME,T3,T4, AdCy,S
• Role of Adjuvant RT yes
• Fast neutron is best.
• Chemo ???? As distant mets in 20

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Future

• Brachy therapy
• Better than Fast Neutron therapy
• Reliable tumor marker
• Newer Imaging modalities
• SPECT for No
• ??? Role of any chemo for Rx of distant mets