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Salivary gland tumors 12 (nx power lite) /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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  • Occurrence at any other site should be considered ectopic. Occurs among whites
  • Well encapsulated
  • Glands of upper lip and buccal mucosa
  • Hence it is difficult for any single institution to compile a large enough experience to define optimal treatment strategies for these tumors
  • Warthins and oncocytic tumors are thought to arise from striated duct cells, acinic cell tumors from acinar cells, squamous and mucoepidermoid ca from excretory duct cells.and mixed tumors from intercalated duct and myoepithelial cells.
  • The actual histopathologic diagnosis or whether the neoplasm is benign or malignant permits surgeon to plan a more precise surgery .
  • Direct invasion of malignant cells through the path of least resistance in the perineural and or endoneural spaces.
  • Mca of soft palate obstrucying oropharyngeal isthmus
  • Sheet of squamous cells with focal mucus producing cells
  • Intermediate grade
  • High grade
  • Most of sal. Gland tumors arise from the epithelium of the duct apparatus , but occasionally lesions seem to show acinar cell differentiation
  • Recurrent adenocarcinoma of palate
  • Regardless of whether they were treated with surgery alone or with surgery and radiation
  • Transcript

    • 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
    • 2. BENIGN TUMORS • Introduction • History • Classification • Incidence • Histogensis • Pathology • Management • Differential diagnosis www.indiandentalacademy.com
    • 3. Heterogenous group of lesions of great morphologic variation. Salivary gland neoplasms – less than 3% of all tumors 1% of all head and neck malignant tumors arise in salivary glands Higher incidence – Eskimos - Survivors of atomic bomb blasts - Persons exposed to pervious radiation Parotid gland tumors – 70% - 80% Submandibular gland tumors – 15% - 30% Sublingual gland tumors – 20% - 51% www.indiandentalacademy.com
    • 4. Arise from any of the numerous , diffuse, intraoral accessory salivary glands. Lip, palate, tongue, buccal mucosa, floor of the mouth and retromolar area. More common – Hard palate Annual incidence (world) – 1to 6.5 cases per 100,000 people Minor salivary gland tumors – common in females www.indiandentalacademy.com
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    • 7. • The anatomy of the parotid gland and the role of the main ducts were - mid-17th century. • The earliest references to "para-auricular swellings," as the Greeks called them, described the findings associated with calculi and inflammation. • From 1650-1750, salivary gland surgery was limited to the treatment of ranulas and oral calculi. www.indiandentalacademy.com
    • 8. • The concept of surgical excision of a parotid tumor has been attributed to Bertrandi in 1802. • The initial applications of this surgery included an extensive approach, causing serious disfiguration and disability • By approximately 1850, the focus shifted toward dissection and the intimate relationship between the facial nerve and the parotid gland. www.indiandentalacademy.com
    • 9. • In 1892 - Codreanu (a Romanian native) performed the first total parotidectomy with facial nerve preservation. • Grafting of the facial nerve after resection was attempted in the early 1950s. • Beahrs and Adson (1958) - described the relevant anatomy and surgical technique of current parotid gland surgery. • They stressed surgical landmarks for avoiding injury to the facial nerve and advocated complete removal of the superficial portion of the parotid gland for noninvasive lesions confined to that portion of the gland. www.indiandentalacademy.com
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    • 21. INTERCALATED DUCT Pleomorphic adenoma Monomorphic adenoma Acinic cell carcinoma Adenoid cystic carcinoma Polymorphus low grade adenocarcinoma Epimyoepithlial carcinoma STRIATED DUCT Warthins tumor Oncocytoma Oncococytic carcinoma www.indiandentalacademy.com EXCRETORY DUCT Salivary duct Ca Papillary adeno Ca High grade Mucoepidermoid Ca Squamous cell Ca Oncocytic Ca
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    • 24. • Parotid glands ( par – near to ; otid – the ear) • Superficial lobe – 75% to 80% of the glandular mass • Deep lobe – 25 to 20% of the mass • 80% of all salivary tumors occur in the parotid gland. • 80% arise in the superficial lobe. • 80% are benign • 80% are pleomorphic adenomas. www.indiandentalacademy.com
    • 25. • Pleos – many : morphus - form • Mixed tumor – mixture of ductal and MIXED TUMOR ENCLAVOMA BRANCHIOMA myoepithelial elements ENDOTHELIOM A ENCHONDROM A www.indiandentalacademy.com
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    • 28. Myoepithelial cell and reserve cell – Intercalated duct Both ductal and myoepithelial cell – play active role Myoepithelial cell – morphologic diversity of the tumor (production of the fibrous, mucinous, chondroid and osseous areas) HUBNER www.indiandentalacademy.com
    • 29. Common tumor Parotid gland – most common site Sublingual gland - rare Lower pole of the superficial lobe of the gland 10% - arise in the deeper portions of the gland 8% - minor salivary glands Palate – most common site (60-65%) Female : Male 6:4 Forth to sixth decades (43yrs) Common in young adults www.indiandentalacademy.com
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    • 31. Small , painless, quiescent nodule Slowly begins to increase in size Sometimes showing intermittent growth Parotid gland – lesion that does not show fixation either to the deeper tissues or to the overlying skin. Irregular nodular lesion Firm in consistency Pain is not a common symptom Local discomfort present Facial nerve involvement – rare. www.indiandentalacademy.com
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    • 33. Attain a size greater than 1-2cm in diameter Difficulties in mastication, talking and breathing Palatal glands – frequent site. Glands of the lip Palatal tumor appear fixed to the underlying bone but not invasive Other sites – freely moveable and easily palpated Recurrent lesions occur as multiple nodules and less mobile www.indiandentalacademy.com
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    • 36. • Irrregular to ovoid mass • Well defined borders • Tumors in major glands – incomplete fibrous capsule • Tumors in minor glands – unencapsulated • Cut surface – rubbery ,fleshy, mucoid or glistening with a homogenous tan or white color • Areas of infarction and hemorrhage. www.indiandentalacademy.com
    • 37. Morpholologic diversity – most characteristic feature Myoepithelial cells – major component www.indiandentalacademy.com
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    • 41. Surgical excision Radiation therapy – contraindicated Rarely malignant tumor may arise Carcinoma ex pleomorphic adenoma Metastasizing benign mixed tumors Metastases – lungs, regional lymph node, skin, and bone. www.indiandentalacademy.com
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    • 43. All Salivary tissue lying deep to the facial nerve – Deep lobe. Need to preserve the facial nerve Limited access to the deep lobe region Presence of the ECA Bounded - Lie posterior to the mandible (bet. the vertical ramus and the mastoid) - Deeply by the styloid apparatus - Do not extend medial to the mandible www.indiandentalacademy.com
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    • 45. • Dumbbell tumor – deep lobe tumors may enter the lateral pharyngeal space through the stylomandibular tunnel. • Dumbbell tumor into pharyngeal space – 1% to 1.7% • Surgical approach – Division of the styloid process or stylohyoid ligament. - Resection of a portion of the overlying vertical ramus - Mandibular osteotomies • Retromandibular deep lobe lesion – Total parotidectomy. www.indiandentalacademy.com
    • 46. a) Sub-sigmoid osteotomy – oblique and straight b) Inverted L osteotomy c) Angle osteotomy d) Parotideal margin osteotomy www.indiandentalacademy.com
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    • 54. Second most common tumor in the salivary glands. Warthin in 1929 Cystic papillary adenoma 4% to 15% of all salivary gland epithelial tumors 4%Branchial cysts of the to 10% of all parotid tumors. Slow growing , cystic neoplasm – exclusively in the parotid parotid gland. Brachiogenic adenoma of the mandible. Frequently – lower portion over the angle Oncocytoma Intraoral accessory salivary glands – rare Predisposing factor – smoking, radiation exposure and Lymphoglandular cystome Epstein barr virus. Adenolymphoma www.indiandentalacademy.com
    • 55. • • • • • • • • • • Round to oval Swelling , well circumscribed masses Multicentric or multifocal disease Typically encapsulated Measures about 2 to 4 cm in diameter. Fifth to seventh decades of life Male : female :: 10:1 Multifocal or bilateral involvement 5% to 14% - bilateral masses. Malignancy - representing less than 1% Recurrence rates – 2% or less. www.indiandentalacademy.com
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    • 62. IF CYSTIC OR PARTIALLY CYSTIC • Lymphoepithelial cysts of HIV positive patients • End stage parotid Sjogrens syndrome IF NOT CAVITATED • Lymphoma • Granulomatous disease (primary sarcoidosis) • Benign adenopathy www.indiandentalacademy.com
    • 63. Applicable in warthin’s tumor Aspiration biopsy – produces cystic fluid (contain tiny, visible tissue fragments Smears – cystic fluid, lymphocytes, and clumps of oncocytic epithelial cells. www.indiandentalacademy.com
    • 64. Tumor is easily removed Minimal loss of glandular function Superficial parotidectomy with preservation of facial nerve Raise – large skin flap Palpation of jugulodigastric and upper cervical nodes Radiation therapy - not recommended www.indiandentalacademy.com
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    • 70. MICROSCOPIC FEATURES TREATMENT EXCISION www.indiandentalacademy.com
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    • 74. Rare benign tumor – 0.1% of all salivary gland tumor Mean age – 58yrs More common in men Tumors ranged 0.42 – 3.0cm in diameter Commonly encapsulated or sharply circumscribed Composed of sebaceous cell nests No tendency to invade local structures. Conservative excision www.indiandentalacademy.com
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    • 76. • To diagnose suspected systemic diseases • Indicated – soft enlargement of one entire gland or of both glands • Normal clinically appearing parotid glands • Contraindicated – discrete firm mass in the parotid • Its value is mainly to diagnose sarcoidosis, Sjogrens syndrome, benign lymphoepithelial lesions and lymphomas www.indiandentalacademy.com
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    • 78. • Primarily surgical (both submandibular and sublingual gland) • Benign or malignant – removal of whole salivary gland • If benign and encapsulated with no potential for recurrence – intracapsular removal • If malignant and potential for recurrence – extracapsular removal www.indiandentalacademy.com
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    • 87. • • • • • • • • • Introduction Etiology Classification Incidence Patient evaluation Imaging modalities Pathology Treatment Outcomes and results www.indiandentalacademy.com
    • 88. Malignant neoplasms of the salivary glands constitute a large collection of highly heterogenous tumors that exhibit a wide spectrum of biologic behaviour, ranging from slow growth and indolence to highly aggressive behaviour and rapid fatality. Malignant tumors of the salivary glands are relatively in frequent. www.indiandentalacademy.com
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    • 94. Cancer of the salivary glands – relatively rare Accounts between 0.3% and 0.9% of all cancers Majority (70%) – parotid gland Three fourths of parotid tumors – benign Majority of tumors – minor salivary glands are malignant Mucoepidermoid carcinoma and adenoid cystic carcinoma – most common. www.indiandentalacademy.com
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    • 101. PAROTID GLAND • Painless swelling • Facial nerve paresis or paralysis • Fixation of the mass to the overlying skin or underlying structures. • Associated cervical adenopathy SUBMANDIBULAR GLAND • Ipsilateral weakness or numbness of the tongue – perineural spread • Enlargement of the submandibular or upper cervical lymph nodes www.indiandentalacademy.com
    • 102. MINOR SALIVARY GLAND Palate most common site Adenoid cystic carcinoma – most histologic type encountered Usually present either as a submucosal mass or as an ulcerative lesion Second most common site – Sinonasal tract Numbness or tingling in the distribution of the branches of the trigeminal nerve – indicate perineural spread. www.indiandentalacademy.com
    • 103. Defines the benign and malignant nature of a salivary gland neoplasm. Indicated for solid mass located within the gland. Sensitivity – 85.5% to 99% Specificity – 96.3% to 100% Accurate, safe, simple to perform and relatively inexpensive. Most diagnostic error – inadequate sampling Ultra sound guided FNAB - when difficult to obtain a representative sample. www.indiandentalacademy.com
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    • 106. • Provides accurate - Delineation of the location - Extent of the tumor - Relation to major neurovascular structures - Perineural spread - Skull base invasion - Intracranial extension www.indiandentalacademy.com
    • 107. • Superior to other imaging techniques or by physical examination. • Demonstrate whether a mass is intraglandular or extraglandular • MRI is superior to CT – internal architecture of salivary gland tumors in a multiplanar fashion • Delineates the interface between tumor and normal salivary gland • Bone destruction of the mandible or skull base – CT • Bone marrow involvement – MRI • High resolution imaging – detecting perineural involvement www.indiandentalacademy.com
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    • 112. POSITRON EMISSION TOMOGRAPHY • Unique method of measuring metabolic activity in various tissues • Detecting recurrence • Distinguishing tumor from post treatment fibrosis • Measure tumor metabolism • Potential to evaluate various biological parameters such as proliferation rates or tumor hypoxia www.indiandentalacademy.com
    • 113. DISADVANTAGES • Variable and inconsistent uptake of fluorodeoxyglucose (FDG) • CT, MRI, and even clinical examination already have high degree of accuracy • High resolution studies – provide anatomic detail • High cost – prohibits its use. www.indiandentalacademy.com
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    • 115. 1942 DOCKERTY AND MAYO – malignant nature of this disease identified. “ ADENOCARCINOMA, CYLINDROMA TYPE” 1953, FOOTE AND FRAZELL coined the term adenoid cystic carcinoma www.indiandentalacademy.com
    • 116. Slow growing, aggressive neoplasm 10% - non squamous carcinomas in the head and neck 15% - all neoplasms of the salivary glands Second most common malignant tumor Common malignant tumor – submandibular, sublingual and minor salivary glands. Two thirds – occur in minor salivary glands www.indiandentalacademy.com
    • 117. • Parotid, submaxillary and accessory glands in palate and tongue– most commonly involved • Commonly seen in females(fifth and sixth decade) • Early local pain (surface ulceration) , facial nerve paralysis, fixation to deeper structures and local invasion • Tendency to spread through perineural spaces (20% to 30%) • Lymph node metastasis – 10% to 30% www.indiandentalacademy.com
    • 118. • Perineural spread – axial and circumferential pattern along the involved nerve and further spread can occur – antegrade and retrograde fashion. • Commonly involved nerves – facial nerve, mandibular and maxillary nerve • Pathway for invasion of the skull base • Tumor cells may reach the trigeminal ganglion, pterygopalatine ganglion or the cavernous sinus. • More frequent – advanced, recurrent and high grade tumors. www.indiandentalacademy.com
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    • 123. • Stewart, Foote and Becker – 1945 • Mucus secreting cells and epidermoid type cells • Most common malignant neoplasm • Seen in submandibular and minor salivary glands • 29 to 34% - salivary gland malignancy • Parotid gland – most common • 80 to 90% - parotid glands • Intraorally - palate www.indiandentalacademy.com
    • 124. • • • • • • • • • Appears as an asymptomatic swelling Aware of the lesion for a year or less Pain or facial nerve palsy may develop Minor glands – second most common site ( palate) Minor salivary gland tumors – asymptomatic swellings Fluctuant and have blue or red color Female predilection Third or fifth decades Most common malignant tumor of children www.indiandentalacademy.com
    • 125. LOW GRADE MALIGNANCY • Slowly enlarging, painless mass and seldom exceeds 5 cm in diameter. • Not completely encapsulated • Often contains cysts – filled with a viscoid, mucoid material • Intraoral lesions – buccal mucosa, tongue, and retromolar areas • Close resemblance to the mucous retention phenomenon or mucocele. www.indiandentalacademy.com
    • 126. HIGH GRADE MALIGNANCY • Grows rapidly and produce pain (early symptom) • Facial nerve paralysis – parotid tumors • Trismus, drainage from ear, dysphagia, numbness of the adjacent areas and ulceration • Infiltrate the surrounding tissue • Metastasize to regional lymph nodes • Distant metastases – lung, bone, brain • Two variants – Sclerosing MEC and Intraosseous MEC www.indiandentalacademy.com
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    • 132. • Conservative excision with preservation of facial nerve – low and intermediate grade MEC of parotid gland. • Affected submandibular gland – removed entirely • Radical neck dissection – evidence of cervical node metastasis • Post operative irradiation – high grade malignancies • Low grade lesions – 5 yr cure rate of 92 % • Intermediate and high grade – 49% 5yr cure rate. www.indiandentalacademy.com
    • 133. • Malignant epithelial neoplasm – neoplastic cells express acinar differentiation • Third most common malignant salivary gland neoplasm www.indiandentalacademy.com
    • 134. • Resembles – Pleomorphic adenoma in gross appearance • Encapsulated and lobulated • Occur chiefly – parotid (80%) • Accessory intraoral glands – occasional • Common intraoral site – lips and buccal mucosa • Predominant – middle age(44yrs) • Female : Male : : 3 : 2 • Slowly growing, mobile or fixed mass of various durations • Facial muscle weakness www.indiandentalacademy.com
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    • 138. SEBACEOUS CARCINOMA PAPILLARY CYSTADENO CARCINOMA (mucus producing MUCINOUS ADENOCARCIN OMA ONCOCYTIC CARCINOMA adenopapillary Ca) CLINICAL FEATURES • • • • • Sebaceous cells 17 – 93 yrs Parotid gland Painful masses Facial nerve paralysis • 0.6 – 8.5 cm • low grade • Major sal.gland 65% • equal distributon • Slowly growing asymptomatic mass • Submandibular gland • Dull pain and tenderness • Soft, spony masses • High grade • parotid gland • 63yrs • pain & paralysis • overlying skin discolored or wrinkled HISTOLOGIC FEATURES • Well circumscribed • Partially encapsulated • Pushing or locally infiltrating margins • Perineural invasion • Prominent cystic and frequently papillary growth but lacking features that characterize cystic variants • Large amount of extracellular epithelial mucin – contains cords, nests, and solitary epithelial cells • Circumscribed but not encapsulated • Foci of oncocytic cells • Perineural or vascular invasion TREATMENT • local excision and • Surgical excision • complete excision parotidectomy • Radiotherapy • With or without www.indiandentalacademy.com chemotherapy • Aggressive initial surgery
    • 139. MESENCHYMAL NEOPLASMS • 1.9 to 5 % of all neoplasms within the major salivary glands. • Classifications pertain to major salivary gland tumors • Benign mesenchymal neoplasms – Hemangioma, lipoma, and Lymphangioma • Malignant mesenchymal neoplasms – malignant Schwannoma, - Malignant fibrous histiocytoma - Rhabdomyosarcoma - Fibrosarcoma www.indiandentalacademy.com
    • 140. Lymphomas of the salivary glands – originate either from Intraglandular lymph nodes (nodal) Lymhoid tissue dispersed within the salivary gland parenchyma (extranodal) • Risk of ML in patients with Sjogren’s syndrome is 44 fold higher ( worst prognosis) • 5% - all extranodal lymphomas affect the salivary glands • 90% - occur in the parotid ( Abundance of lymphoid aggregates within its salivary parenchyma) • Most salivary gland lymphomas – non Hodgkins variety (85%) www.indiandentalacademy.com
    • 141. Hematogenous metastases – lung, kidney and breast Parotid gland most common site Lymphatic spread from cutaneous malignancy of the head and neck Less than 10% - malignant parotid gland tumors 40% - melonomas 40% - Squamous cell carcinomas Two thirds of metastatic squamous cell Ca to the parotid occur within first year after treatment of the primary skin cancer www.indiandentalacademy.com
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    • 144. UNTREATED RESECTABLE Clinically suspicious of cancer > 4cm or deep lobe Clinically benign <4cm (T1, T2) Complete surgical excision Benign Low grade mucoepidermoid CT/MRI Base of the skull to clavicle Surgical resection Intermediate or high grade Follow up Consider FNA Benign Superficial lobe N0 Parotidectomy Follow up Cancer RT N+ Deep lobe N0 Parotidectomy + Total comprehensive Parotidectomy neck dissection www.indiandentalacademy.com N+ Total Parotidectomy + comprehensive neck dissection
    • 145. PREVIOUSLY TREATED INCOMPLETELY RESECTED H&P CT/MRI Pathology Review Negative physical exam + imaging Adjuvant RT Follow up Gross residual disease on physical examination or imaging Surgical resection if possible Adjuvant RT www.indiandentalacademy.com No surgical resection possible Definitive RT Follow up
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    • 147. CANCER SUPERFICIAL LOBE DEEP LOBE Completely excised No adverse characteristics Parotidectomy Incompletely excised gross residual disease No further surgical resection possible Adverse characteristics Adjuvant RT Definitive RT Surgery +/Adjuvant RT RT if feasible or clinical trial or single agent chemotherapy or best supportive care Resectable Chest x ray annually TSH annually if thyroid irradiated Not Resectable www.indiandentalacademy.com Physical examination Year 1 (every 1-3 mon) Year 2 (every 2-4 mon) Year 3-5 (every 4-6 mon) >5yr (every 6-12 mon)
    • 148. PARAPHARYNGEAL SPACE Primary salivary gland neoplasm Transcervical submandibular approach Parotid neoplasms that extend from the deep lobe Superficial parotidectomy with facial nerve identification Resection of deep lobe and parapharyngeal tumor Massive or recurrent benign neoplasms and invasive malignant neoplasms – Anterior mandibulotomy and mandibular swing Complete tumor resection – Transcervical – transoral approach www.indiandentalacademy.com
    • 149. • Resection alone is adequate surgery – low grade malignancies confined to the gland • Other malignancies – removal of the contents of the submandibular triangle (submandibular gland) • Locally invasive tumors – surgical resection extended to include the involved structures with an appropriate tumor free margin. www.indiandentalacademy.com
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    • 151. • Improve local control – after surgery to appropriately selected patients • Indicated in all malignancies, except low grade stage I tumors • Armstrong et al. – local control was excellent for stage I and Stage II malignancies • Recommended – high grade tumors and stage III and stage IV tumors INDICATIONS • Close or positive surgical margins • Perineural or perilymphatic invasion • Intraparotid or regional nodal metastasis • Recurrent diseases www.indiandentalacademy.com
    • 152. POST OPERATIVE NECK IRRADIATION AFTER NECK DISSECTION • Solitary metastatic nodes greater than 1 cm • Multiple metastatic nodes • Extracapsular extension Elective neck radiation therapy for minor salivary gland malignancies – not recommended www.indiandentalacademy.com
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    • 154. • Muiltivariate analysis – Advanced stage, higher histologic grade and submandibular location – poorer outcome • 10 yr survival rates for stage I, II, III & IV tumors – 82%, 64%, 50%, 33% • Tumor histopathology – dominant prognostic factor for salivary gland malignancies. • Regional lymph node metastases – poorer prognosis www.indiandentalacademy.com
    • 155. • Larger tumor size – higher rate of regional lymph node metastases • Distant metastases – poor prognosis • Parapharyngeal space extension – poor prognosis • Parotid malignancies – better prognosis • Facial nerve paralysis – poor prognosis • Men – poorer outcomes www.indiandentalacademy.com
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    • 157. PARAPHARYNGEAL TUMOR www.indiandentalacademy.com
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    • 161. Intra-oral approach with Le fort I osteotomy www.indiandentalacademy.com
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    • 164. • Clinical parameters such as advanced stage, high grade, nodal metastasis, positive margins, and perineural spread characterize patients with aggressive and potentially lethal tumors • The relatively high rate of failure to control the disease in these patients indicates the need for improvement in adjuvant therapy. www.indiandentalacademy.com
    • 165. • Text book of oral pathology; shafers – 5th edition • Color atlas and text of the salivary glands diseases – John Norman. • Head and neck cancer, second edition – Louis .B. Harrison • Cancer of the head and neck, Eugene . myers – 4th edition • Diagnostic imaging of head and neck – Harnsberger • The comprehensive management of Salivary gland pathology – Eric Carlson Oral and Maxillofacial Surgical Clinics of North America Aug 1995 www.indiandentalacademy.com
    • 166. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com