Salivary glands cancer

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some clinical notes about types and management of salivary gland malignancy..

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Salivary glands cancer

  1. 1. Salivary Glands Cancer By Osama El-Zaafarany
  2. 2. Epidemiology • Salivary gland neoplasms account for 6% of H&N cancers (35% are malignant). • Less than 0.3% of all malignancies. • Approximately 80% of all salivary gland neoplasms originate in the parotid. • The male-to-female ratio for malignant salivary gland tumors is 0.6. • About 25% of parotid, 40% of submandibular, and 75% of sublingual gland tumors are malignant.
  3. 3. Etiology • Lifestyle: Cigarette smoking has a strong association with Warthin’s tumor, a benign tumor of the parotid gland • Occupational: Hairdressers, rubber manufacturing, exposure to metal in the plumbing industry and nickel compounds, and woodworking in the automobile industry • Ethnic: Inuit men and women have the highest incidence rate of salivary gland cancer in the world, primarily from an excess of lymphoepithelial carcinomas • Ionizing radiation: (including 131l): risk factor mostly for mucoepidermoid carcinomas and Warthin’s tumors. An increased risk has also been observed for adenocarcinomas among Hodgkin lymphoma survivors. • Epstein-Barr virus: lymphoepithelial carcinomas
  4. 4. Anatomy
  5. 5. Pathology WHO 2005 classification of malignant salivary epithelial tumors
  6. 6. Natural History • Mucoepidermoid carcinoma is the most common malignant diagnosis (33%), followed by adenoid cystic carcinoma (24%), polymorphous low-grade adenocarcinoma, carcinoma ex pleomorphic adenoma. • Mucoepidermoid carcinoma has higher incidence for LNs metas. • Adenoid cystic carcinoma:  25-50 % distant metas.  PNI.  Needs adjuvant RTx.  Not respond to Taxol.
  7. 7. Regional lymph node metastases • Mainly to levels II & III. • This figure shows the percentage of LNs metas in Parotid gland cancers:
  8. 8. Risk of positive neck nodes according to summation of scores and site:
  9. 9. Workup • H&P with bimanual palpation. Carefully examine cranial nerves and for trismus. • CT and/or MRI of head and neck. • PET scan is still investigational for salivary gland cancers. • Fine-needle aspiration biopsy. • Chest X-ray. • Dental evaluation prior to the start of RT.
  10. 10. Staging
  11. 11. Treatment Recommendations
  12. 12. • Surgery forms the mainstay of defnitive treatment for salivary gland malignancies. • Complications of surgery include facial nerve dysfunction and Frey’s syndrome; (gustatory flushing, sweating, auriculotemporal syndrome(. • Superfcial parotidectomy can generally be performed for:  low-grade parotid tumors.  T1–T2 superficial parotid lobe tumors without facial nerve invasion. • Neck dissection recommended for:  clinically +ve LNs.  high-grade tumors.
  13. 13. • Indications for post-op RT are currently controversial as there is no randomized data analyzing the role of post-op RTx. • Consider post-op RTx for:  PNI.  close/+ve margins.  high-grade tumors.  T3-4 tumors.  +ve LNs.  +ve Vascular invas. • RT alone (definitive) is indicated for medically inoperable and unresectable tumors. • LC rates with RTx alone range from 20-80%.
  14. 14. • Neutron therapy may achieve better LC for unresectable or inoperable tumors. • Brachytherapy or intraoperative RT can be considered for recurrent tumors. • IMRT reduces mean doses to normal structures and allows dose-escalation to tumor.
  15. 15. RTx dose • Post-op RT :  -ve margins: 60–63 Gy at 1.8–2 Gy/fx  +ve margins: 66 Gy at 1.8–2 Gy/fx  for gross residual disease: 70 at 1.8–2 Gy/fx • RT alone (definitive): 70 at 1.8–2 Gy/fx • Elective neck RT: 50–54 Gy at 1.8–2 Gy/fx.  Ipsilat.  Levels I-II-III.  For tumors > 4cm include levels IV, V.
  16. 16. Field Arrangements (Parotid Gland Tumors) • Two traditional radiation therapy techniques for parotid gland tumors; unilateral anterior and posterior wedge pair fields using either:  4-6 MV photons or 60Co.  12-16 MeV electron (80% of dose) in combination with 4-6MV or 60Co photons (20% of dose). • Target:
  17. 17. Metastatic disease • CAP regimen: cyclophosphamide (500 mg/m2), doxorubicin (Adriamycin; 50 mg/m2), and cisplatin (Platinol; 50 mg/m2) on first day of a 28-day regimen. • The objective response rates to chemotherapy are modest, ranging from 15 to 50%, and lasting from 6 to 9 months. • Paclitaxel 200 mg/m2 every 21 days (no response in adenoid cystic carcinoma) • Targeted therapy may prove useful in the future as some histologies express EGFR, C-kit, and/or HER-2
  18. 18. Evidence Role of adjuvant RTx: Dutch Head and Neck Cooperative Group (NWHHT), 2005:
  19. 19. Role of neutron RTx: University of Washington, 2003:
  20. 20. Role of Elective Neck Irradiation University of California, San Francisco (UCSF), 2007:
  21. 21. Follow-Up • H&P:  every 1–3 months for 1 year.  every 2–4 months for second year.  every 4–6 months for years 3–5.  annually thereafter. • Regular head imaging with MRI and CXR as indicated. • TSH every 6–12 months if neck irradiated.

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