Salivary gland tumors by J. Shaha

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Salivary gland tumors by J. Shaha

  1. 1. The International Federation of Head and Neck Oncologic SocietiesCurrent Concepts in Head and Neck Surgery and Oncology 2012 Management of Salivary Gland Tumors Ashok R. Shaha
  2. 2. Salivary Glands Major: Parotid Submandibular Sublingual Minor salivary glands:600 - 800 all over the upper aerodigestive tract2012 Majority on the palate
  3. 3. Salivary Literature 1985 to 2005 Subject # Papers Salivary gland diseases 19,754 Salivary neoplasms 7,914 Needle biopsies 14,713 Salivary – needle biopsies 3972012
  4. 4. Salivary Gland Neoplasms Management Issues Evaluation (FNAB, CT, MRI) Stage v. Grade Imaging Facial nerve Adjunctive radiotherapy2012 Definitive radiotherapy
  5. 5. Salivary Tumors Sites of OriginSites # Pts %Parotid 1,965 70.0Submandibular 235 8.4Palate 228 8.0Lips/Cheek 73 2.6Antrum 72 2.6Tongue 63 2.2Nasal cavity 60 2.1Gingiva 34 1.2Floor of mouth 22 0.8Larynx 21 0.8Tonsil 13 0.5Ethmoid 9 0.3Nasopharynx 9 0.3Pharyngeal wall 3 0.12012 TOTAL 2,807 100.0
  6. 6. Salivary Gland Neoplasms* PROPORTION MALIGNANT # Pts 2500 Benign Malignant 2000 25% 1500 1000 82% 500 57% 0 Parotid Submandibular Minor n=1965 n=235 n=6072012 *MSKCC 1939-73 (Head Neck Surg 1986)
  7. 7. Salivary Tumors - Histologic Distribution Parotid Sub - Max Mucoepidermoid Adenoid cystic Minor Adenocarcinoma Malignant mixed Acinic cell2012 Squamous Other
  8. 8. Palate Tongue Cheek/Lip Antrum Nasal Cavity Gum Larynx Tumors of Minor FOM Salivary Glands. Tonsil Site DistributionNasopharynx Ethmoid Pyriform Other 2012 0 10 20 30 40 %
  9. 9. Parotid Tumors Pathology – Memorial Hospital, 1939-1973 (N=1973)Benign (n=1342) Malignant (n=631)Pleomorphic adenoma 1133 Mucoepidermoid 272Warthin’s 183 Adenocarcinoma 62Oncocytoma 20 Acinic cell 75Monomorphic 6 Adenoid cystic 62 Ca ex pleomorphic 107 Undiff 8 Epidermoid 45 2012 Spiro, 1986, Head and Neck Surg
  10. 10. Modification of WHO and AFIP Classifications to Denote Grade of Salivary Gland Tumor Low-grade High-grade Acinic cell carcinoma  Polymorphous low grade  adenocarcinoma  Basal cell adenocarcinoma  Sebaceous carcinoma  Papillary cystadenocarcinoma  Mucinous adenocarcinoma  Basal cell adenocarcinoma  Sebaceous carcinoma  Papillary cystadenocarcinoma  Mucinous adenocarcinoma Malignant myoepithelialioma  2012 Watkinson, 2001
  11. 11. Modification of WHO and AFIP Classifications to Denote Grade of Salivary Gland Tumor Low-grade High- grade Mucoepidermoid carcinoma   Adenoid cystic carcinoma   Adenocarcinoma, NOS   Epithelial-myoepithelial carcinoma  Oncocytic carcinoma  Salivary duct carcinoma  Carcinoma in pleomorphic adenoma  Squamous cell carcinoma  Small cell carcinoma  Undifferentiated carcinoma 2012 Watkinson, 2001
  12. 12. Presentation Lump Pain Facial weakness Neck metastases Parapharyngeal mass – deep lobe tumors2012
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  17. 17. Salivary Gland Tumors • Dumb bell tumor • Deep lobe tumor • Parapharyngeal space • Extraparotid salivary tissue2012
  18. 18. Parotid Carcinoma: Obvious Signs •  Facial nerve palsy •  Cervical metastasis •  Skin involvement2012
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  21. 21. Investigations •  Clinical evaluation •  Sialogram •  CT scan •  CT sialogram •  Needle biopsy2012 •  Sialendoscopy
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  23. 23. Parotid Tumors Indications for CT Scan •  Clinical uncertainty of findings •  Deep lobe presentation •  Extraglandular extension •  Cervical nodal involvement2012 •  Facial palsy or fixed mass
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  26. 26. Indications for Anatomical Imaging •  To make the diagnosis •  Uncertain extent •  Size •  Fixation •  Recurrent •  Parapharyngeal2012 •  Clinically malignant
  27. 27. Role of Imaging 1. CT scanning is superior to MRI for osseous and skull base involvement but MRI is superior for intracranial extension of tumour 2. MRI is superior to CT for assessment of primary disease and regional recurrence, as well as characterising extra parotid extension. Perineural invasion is best characterised with MRI2012 3. Minor salivary gland tumours are best imaged with MRI, with irregular margins being a feature Robson, 2002
  28. 28. Role of Needle Biopsy in Salivary Tumors•  To suspect malignancy•  To distinguish from metastatic carcinoma•  To suspect lymphoma•  To distinguish salivary from non-salivary tumors •  In poor risk pt - if suspect Warthin’s tumor •  To confirm pre-op suspicion of malignancy in pts with facial palsy •  In bilateral tumors2012 •  Minimum risks Shaha AR. Am J Surg
  29. 29. Mass in Parotid Region History/Head & Neck Exam FNA Salivary Non-Salivary Benign Malignant Lipoma Seb. CystMixed tumor Primary Metastatic Lymph NodesWarthin’s Ad-Cystic Sq Ca. Benign Adeno Ca. Melanoma Melanoma Met Ca.2012 Lymphoma
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  31. 31. Salivary Gland TumorsGeneral Principles of Treatment •  Tumor factors •  Patient factors •  Physician factors2012
  32. 32. Parotid Tumor Surgical Principles Every attempt should be made to remove all gross tumor. Radiation therapy does not compensate for inadequate surgery.2012
  33. 33. Parotid Tumor Surgical Principles The extent of parotidectomy depends more upon the extent of the tumor than the histology of the tumor.2012
  34. 34. Salivary Gland Carcinoma Treatment Principles The anatomic relationship of the tumor to the nerve dictates the extent of surgery, not the histologic classification of the neoplasm.2012
  35. 35. Malignant Tumors Surgical treatment of the primary tumour - Parotid Gland: •  Size and location determine extent of resection •  Most T1/T2 lesions lateral to the nerve are suitable for a superficial parotidectomy •  Larger and deep lobe tumours usually require a total conservative parotidectomy with preservation of the facial nerve •  Patients with high grade extensive disease (i.e. skin involvement or facial palsy) may require extended radical parotidectomy •  In one series, facial nerve dysfunction was apparent initially in 14% of patients and complete nerve sacrifice was required in about 30% of2012 parotidectomies
  36. 36. Indications of Facial Nerve Resection•  Pre-op facial palsy•  Large tumor adherent to the nerve•  Direct tumor involvement into thenerve•  Recurrent malignant tumor2012
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  38. 38. Resection of Facial Nerve •  Nerve graft •  Great auricular nerve •  Ansa Cervicalis •  Sural nerve •  Nerve transfer-hypoglossal transfer •  Tarsorrhaphy •  Facial reanimation - facial slings2012
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  41. 41. Problem Areas in Salivary Tumors: Parotid Gland •  Deep lobe parotid tumors •  Accessory parotid tumors •  Regional node metastases •  Local recurrences •  Facial nerve? 2012
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  54. 54. Warthin’s Tumor •  Papillary cystadenoma lymphomatosum •  Oncocytoma •  Branchiogenic adenoma •  Epitheliolymphoid •  Branchioma •  Cylindrocellular branchiogenic adenoma •  Orbital inclusion adenoma2012
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  56. 56. Prognostic Factors •  Clinical Stage (TNM) •  Histological grade •  Age •  Gender •  Anatomical site •  Experience of the surgeon2012
  57. 57. Ca of the Parotid, MSKCC 1939-1968 Factors Influencing “Cure” Pts Eligible NED %Cervical node metastasis: Never documented 213 157 74 Present on admission 57 5 9 Appeared later 18 3 17Local recurrence*: No 194 153 79 Yes 71 15 21 2012 *No data or palliation only in 23
  58. 58. Ca of the Parotid, MSKCC 1939-1968 Factors Influencing “Cure” Pts Eligible NED % Stage of primary: I 104 88 85 (92) * II 83 57 67 (75) III 99 19 19 (20) Facial nerve status: Function intact 212 139 66 Partial/complete palsy 43 6 14 Not recorded 31 18 58 Unrelated dysfunction 2 2 1002012 *Determinate cases only
  59. 59. Major Salivary Ca 1939-1982 Node Metastasis (26%) # Pts* Nodes + Anaplastic 6 5 (83%) Squamous 26 15 (58%) Mucoep grades 2,3 123 54 (44%) Adenocarcinoma 46 18 (39%) Malig mixed 62 12 (19%) Adenoidcystic 50 4 (8%) Acinic cell 56 4 (7%)2012 Mucoep grade 1 68 2 (3%) *439 determinate pts
  60. 60. Cancer of the Major Salivary Glands: Nodal Status & 5 Yr Survival 80 70 N0 60 N+ 50 40 30 20 10 0 Parotid Submandibular2012
  61. 61. Elective Neck Treatment in Salivary Gland Cancers•  High grade tumors•  T3 (?) & T4 tumors Elective•  Tumors >3 cm neck•  Facial paralysis treatment•  Age >54•  Extraparotid extension•  Perilymphatic invasion2012
  62. 62. 1966 – 1998 Neck Dissection for Parotid Ca - MSKCC •  Therapeutic neck dissection with post-op RT yielded better results •  Reserve elective neck dissection for selected pts •  Indications for elective neck dissection •  High risk of metastasis based on T stage & grade •  Selected pts with large primary tumors in the tail of parotid2012
  63. 63. Management of the Neck in Parotid Cancer Elective neck dissection should be reserved for those histologic diagnoses having the highest risk of nodal metastases plus selected patients whose primary tumor resection may be facilitated by2012 Lymphadenectomy. Kelley and Spiro. Am J Surg 1996; 172:695-697.
  64. 64. Indications for Postoperative Irradiation-Parotid Cancer •  Aggressive, highly malignant tumors •  Invasion of adjacent tissues outside parotid capsule •  Regional lymph node metastases •  Deep lobe cancers •  Gross residual tumor following resection •  After resection recurrent tumor2012 •  Tumor invasion of facial nerve
  65. 65. Salivary Ca. - Impact of Post-op R.T. on Survival 100 75 50 % 25 0 0 5 10 Time (years) Stage I, II Stage I, II w/ Stage III, IV Stage III, 2012 RT w/ RT IV
  66. 66. Adjuvant Radiotherapy: Impact on Prognosis Survival Surg Alone Surg+RT Stage I/II 96 82 Stage III/IV 10 51 Lymph node mets 19 49 High-grade tumors 28 57 Overall 55 69 Local control Surg Alone Surg+RT Stage I/II 79 91 Stage III/IV 17 51 Lymph node mets 40 69 High-grade tumors 44 632012 Overall 66 73 Armstrong, et al. Arch Oto HN Surg 1990.
  67. 67. Salivary Carcinoma - Survival by 100 HISTOLOGY 80% 60 40 20 0 0 6 12 18 24 30 36 Time (years) Acinic cell Muco ep. Gr II - MMT Squamous or2012 III Anaplastic ca Muco ep. Gr I Adeno Ca. Adenoid cystic
  68. 68. Salivary Carcinoma - Survival by SITE 100 Parotid Sub-max 80 Minor 60% 40 20 0 2012 0 5 10 15 20 Time (years)
  69. 69. Salivary Carcinoma - Survival by GRADE 100 Low 75 Intermediate%50 High 25 p< 0.0001 0 0 5 10 15 202012 Time (years)
  70. 70. Salivary Carcinoma - Survival by STAGE 100 Stage I 75 Stage II% 50 Stage III 25 P< 0.0001 02012 0 5 10 15 20 Time (years)
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  72. 72. Important Prognostic Factors in Salivary Tumors •  Age at diagnosis •  Pain at presentation •  T stage •  N stage •  Skin invasion •  Facial nerve dysfunction •  Perineural growth •  Positive surgical margins •  Soft tissue invasion2012 •  Treatment type Vander Poorten, 2002.
  73. 73. Radiation Therapy: Fast Neutron Radiation •  Available in few centers •  High LET radiation •  RBE especially high for adenoid cystic ca •  Uncertain benefit in completely resected vs conventional photon RT •  Definite advantage residual, recurrent2012 unresectable disease
  74. 74. Fast Neutrons as Treatment for Salivary Gland Carcinoma* •  53 pts (24 gross resid p.o.; 13 inop; 16 rec p.o.) •  Locoreg control in Rx field in 48 (>90%) •  ACC = 14 pts (42 mos med f/u – min 1 yr) •  Actuarial 5 yr survival 33% (42% No) •  17% serious acute complic (Incl 1 death)2012 *Buchholz et al. Cancer 1992
  75. 75. Post-Op Complications •  Hematoma •  Infection •  Numbness of the skin •  Seroma salivary fistula •  Frey’s syndrome •  Facial weakness2012
  76. 76. Frey’s Syndrome Treatment: •  Anticholinergic cream •  Resection of auriculo-temporal nerve •  X-ray treatment •  Intracranial sectioning of IX nerve •  Excision of involved skin •  Jacobsen’s neurectomy •  Alcohol injection in otic ganglion2012 •  Elevation of skin flap and dermis or fascia lata graft
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  79. 79. Submandibular Gland Tumors •  Known or suspected tumour requires extracapsular excision •  Invasive tumours require wide local resection2012
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  81. 81. Minor Salivary Gland Tumors •  Histological type influenced the development of nodal disease, being more common in mucoepidermoid and high grade tumours. •  Perineural invasion reduced 5-year survival from approx 95% to 35%, and increased the likelihood of nodal disease and distant metastases. Involvement of named nerves led to a particularly unfavourable prognosis.2012 •  Adenoid cystic primaries require more generous margins due to perineural spread Robson, 2002
  82. 82. Salivary Tumors Molecular Biology •  Loci on chromosome 8q may harbor a tumor suppressor gene or genes associated with development or progression of salivary tumors •  Alterations on the short arm of chromosome 17 may represent an event related to tumor progression •  Tumors with LOH at multiple loci have aggressive biologic characteristics 2012
  83. 83. Salivary Tumors Molecular Biology•  Warthin’s tumor showed low SPF+G2M and low Ki67•  Pleomorphic adenoma showed low SPF+G2Mand high Ki67•  Malignant tumor showed high SPF+G2M andhigh Ki67•  MIB 1 and PCNA immunohistochemistry mayhelp distinguish benign/low grade/ACC 2012
  84. 84. Salivary Diseases •  Outpatient parotidectomy •  Needle biopsy •  Sialoendoscopy •  Sialocholithotomy •  Molecular markers2012 •  Radiation therapy
  85. 85. Salivary Gland Carcinoma Rx Principles •  Adequate local excision of tumor based on extent of the primary •  Preserve the nerve, if possible •  Elective neck dissection reserved for selected patients •  Post-operative radiotherapy when indicated (appropriate fields)2012 •  Most important prognostic factors: stage & grade
  86. 86. “In seventh nerve paralysis, joy, happiness, sorrow, shock, surprise, all the emotions have for their common expression the same blank stare.” Sterling Burnell, 19272012

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