Detailed description of salivary tumors

1. SALIVARY TUMORS
DEPARTMENT OF GENERAL SURGERY

2. 1.Mid-17th century –
 Anatomy of the parotid gland and the role of the main ducts.
Greeks called "para-auricular swellings" - described findings associated with
calculi and inflammation.
 IN 1650-1750 , salivary gland surgery was limited to the treatment of ranulas and oral
calculi.
 Bertrandi in 1802 - The concept of surgical excision of a parotid tumor
Initial surgeries - serious disfiguration and disability
 By1850, the focus shifted toward dissection and the intimate relationship between the
FN and the parotid gland
 Codreanu (1892) - First total parotidectomy with facial nerve preservation.
 Early 1950s - Grafting of the facial nerve after resection.
 Beahrs and Adson (1958) - Surgical technique of current parotid gland surgery.
 *They stressed surgical landmarks for avoiding injury FN
 *Advocated complete removal of the superficial portion for benign
lesions confined to that portion of the gland

3. TYPES
 Salivary Glands are divided into
1- major salivary glands
2- minor salivary glands
3- ectopic salivary glands
 In which major salivary glands are further divided into three pairs as
a. Parotid glands
b. Submandibular glands
c. Sublingual glands
 Minor salivary glands :around 450 in number
distributed in lips,cheeks,palate and floor of the mouth
also present in oropharynx,larynx,trachea,and paranasal sinus
contribute about 10%of total salivary volume

4. Major salivary glands
 Major salivary glands are further divided into three
pairs as
a. Parotid glands
b. Submandibular glands
c. Sublingual glands

5. PAROTID GLANDS
 Largest salivary gland
 Location:
Below the acoustic meatus between the ramus of mandible and
sternomastoid muscle.
 The deep cervical fascia splits to form a capsule (parotid capsule )to enclose the gland.
 The superficial layer is thickened and adherent to the gland.
 It is deep to parotid fascia ,superficial to masseter, so parotid swelling occupies
below,behind,in front of the ear lobule.
 PARTS OF PAROTID GLAND:FACIAL NERVE DIVIDES THE PAROTID INTO TWO PARTS
 Superficial part(80%)-lies over the posterior part of the ramus of the mandible
 Deep part(20%)-lies behind the mandible and medial pterygoid muscle, in relation to
mastoid and styloid process.

6.  Parotid duct:-
Also known as Stenson's duct .
It is 2-3 mm in diameter,5 cm in length, emerges from anterior surface of the gland, runs
over the surface of the masseter muscle, passes through the buccinators muscles,and
opens into the oral mucosa opposite to the crown of second molar tooth.
 Blood supply ;-
 Artery supply by external carotid artery.
 Superficial temporal artery
 Maxilla artery - deeper to venous plane
 Venous drainage is by external jugular vein.
 NERVE SUPPLY:-
 Mainly from autonomic nervous system
 Parasympathetic is secret motor from aurico temporal nerve.
 Sympathetic is vasomotor from plexus around the external carotid artery.
 Faciovenous plane of patey is of surgical importance.

7.  LYMPHATIC DRAINAGE:-
DRAINS INTO PAROTID LYMPH NODES WHICH ARE PARTLY INTRAGLANDULAR AND
PARTLY EXTRAGLANDUAR.
 SUBMANDIBULAR SALIVARY GLAND :-
 ‘J” SHAPED SALIVARY GLAND ,SITUATED IN ANTERIOR PART OF THE DIGASTRIC TRIANGLE.
 DIVIDED INTO TWO PARTS :-
 SUPERFICIAL PART :LIES IN SUBMANDIBULAR TRIANGLE ,SUPERFICIAL TO MYLOHYOID AND
HYOGLOSSUS MUSCLES,BETWEEN THE TWO BELLIES OF DIGASTRIC MUSCLE.
 DEEP PART :- FLOOR OF THE MOUTH AND DEEP TO THE MYLOHYOID.
 SUBMANDIBULAR(WHARTON’S )DUCT ,EMERGES FROM THE ANTERIOR END OF THE DEEP PART OF
THE GLAND,ENTERS THE FLOOR OF THE MOUTH,ON THE SUMMIT OF PAPILLA BESIDE THE FRENULUM
OF THE TONGUE.
 VENOUS SUPPLY :- ANTERIOR FACIAL VEIN
 NERVE SUPPLY :- SUBMANDIBULAR GANGLION

8.  SUBLINGUAL GLANDS:-
PAIRED AND LOCATED IN THE ANTERIOR ASPECT OF THE FLOOR OF THE MOUTH IN RELATION TO
MUCOSA ,MYLOHYOID MUSCLE,BODY OF THE MANDIBLE NEAR MENTAL SYMPHYSIS.
DRAINS INTO MUCOSA THROUGH A DUCT ,WHICH DRAINS INTO SUBMANDIBULAR
DUCT(BURTHOLIN DUCT)

9. MINOR SALIVARY GLANDS
 Minor salivary glands :
 Around 450 in number
 Distributed in lips,cheeks,palate and floor of the mouth
 Also present in oropharynx,larynx,trachea,and paranasal sinuses
 Contribute about 10%of total salivary volume .
 Not present in gingivae and anterior aspect of the hard palate
 Ectopic Salivary Gland:
 Also called as aberrant salivary gland, it is nothing but ectopic lobe of the
juxtaposed salivary gland And the commonest is stafne bone cyst
 Stafne bone cyst is invagination of the juxtaposed submandibular salivary gland
into the mandible bone on its lingual aspect

10. SALIVARY NEOPLASMS
 AETIOLOGY :-
 GENETIC –LOSS OF ALLELES OF CHROMOSOME IN 12q,8q,17q
 INFECTIVE—MUMPS,EPSTEIN-BARR VIRUS,CHRONIC SIALADENITIS
 RADIATION
 SMOKING—ADENOLYMPHOMA OF WARTHIN’S SHOWS 40%RISK IN SMOKERS
 SEX---BENIGN TUMORS AND MANY MALIGNANCIES ARE COMMON IN
FEMALES,WARTHIN’S AND SOME MALIGNANCIES ARE COMMON IN MALES
 ENVIRONMENT AND DIET

11. CLASSIFICATION
 ACCORDING TO WHO ,IT IS CLASSIFIED AS
EPITHELIAL
NON EPITHELIAL
MALIGANT LYMPHOMAS
SECONDRAY TUMORS FROM HEAD AND NECK
REGION;BRONCHUS AND SKIN
LYMPHO EPITHELIAL TUMOURS

12. EPITHELIAL(90%) :-
ADENOMAS
Pleomorphic adenomas
Monomorphic adenomas
Adenolymphoma(Warthin’s tumour)
Oncocytoma(oxyphil adenoma)seen in elderly:seen in
parotid gland
Basal cell adenoma----it is a rare benign tumour
Carcinomas
Mucoepidermal carcinoma-most common malignancy
Acinic cell carcinoma
Adenoid cystic carcinoma-very aggressive -10%;common in minor
salivary glands
Adenocarcinoma
Squamous cell carcinoma-2%
Carcinoma in ex pleomorphic adenoma
Undifferentiated carcinoma

13.  NON EPITHELIAL ;
 HEMANGIOMA-commonly seen in infants,usually in parotids.
Spontaneous regression is common .
Most common beningn tumour in paediatric age group.
 Lymphangioma
 Neurofibromas and neurolemmmoma
 MALIGNANT LYMPHOMAS___NON HODGKINS LYMPHOMA TYPE:
 Common in parotids
 Common with HIV,Sjogrens syndrome
 LYMPHOEPITHELIAL TUMOURS:-
 Benign—5% of all benign salivary tumours
common in females and ,can be bilateral
 Malignant---
it is rare tumour occurs in parotid and submandibular glands.

14. BENIGN SAIVARY GLAND TUMORS
. General Characteristics
1.• Grow slowly, •
2. Asymptomatic,
3.• Do not fluctuate in size
4.• Usually of long duration
5.• Present a single nodule
6. • Not fixed to overlying skin or mucous membrane
7. • Recurrent lesion may be multi- nodular

15. Pleomorphic Adenoma
• Benign glandular neoplasm
• Incidence: common ,70% of salivary tumors
• Gender: female > male
• Age: 3-6th decades
• Site: parotid, palate, upper lip, buccal mucosa
• Symptoms: slow growing painless mass
• Gross Pathology: - well circumscribed firm tan white solid or
partially cystic mass
• Histology: - ductal epithelial cells - myoepithelial cells -
stroma: myxoid, chondroid, fibrohyaline

18. Treatment:
• Surgical excision
• Superficial parotidectomy
• Prognosis: excellent
• Complications:
• recurrence – multifocal
• malignant transformation (5%)

19. WARTHIN’S TUMOR (PAPILLARY CYSTADENOMA
LYMPHOMATOSUM)
• Benign salivary gland tumor
• Incidence: common
• Gender: male > female
• Age: 5-7th decades
• Symptoms: painless mass
• Site: parotid, multi-focal/bilateral (14%)
• Etiology: smoking (8 fold risk) 23

21. Treatment :-
• Surgical excision
• Superficial parotidectomy
• Prognosis: excellent
• Complications:
• Recurrence – 6-12% (multicentric)
• Association with other salivary tumors
• Malignant transformation – extremely rare

22. ONCOCYTOMA
1.• Benign salivary gland neoplasm •
2. Incidence: rare (1% of salivary tumors)
3.• Site: parotid gland (85-90%)
4.• Age: 6-8th decades
5.• No gender predilection
6. • Symptoms: painless mass (<4 cm)
7. • Multifocal/bilateral

24. Treatment
• Surgical excision
Prognosis
• Excellent
• Recurrence uncommon
Complication
• Oncocytic Adenocarcinoma - sinonasal tract

25. Ductal Papillomas :- Present in three forms
• simple ductal papilloma
• Inverted ductal papilloma
• Sialadenoma papilliferum
1. Simple ductal papilloma –
 Exophytic lesion,
 papillary surface and pedunculated base –
 Reddish in color present on palate or buccal mucosa
 -It consist of non-keratinized epithelium, columnar, supported by a core of vascular fibrous
connective tissue
 Inverted ductal papilloma –
 Present as a nodule of oral mucosa of adults.
 No distinctive clinical features –
 Histologically it consist of squamous, cuboidal,or columnar cells which proliferate into duct
to form a bulbous masses.
 Mucous cells and micro cyst with mucous may be seen
 Sialadenoma Papilliferum –
The lesion occurs in adults –
 Exophitic papillary lesion of hard palate
 Histologicaly ,Luminal layer of columnar cells on cuboidal basal layer
. -Connective tissue papillae contain plasma cells

26. Monomorphic adenoma
• Consists of single epithelial cells type
• Basal cell, canalicular, sebaceous, glycogen-rich, clear cell
• Most common types are - Basal Cell Adenoma
- Canalicular Adenoma
 Canalicular Adenoma
• Benign salivary gland neoplasm
• Monomorphic adenoma
• Site: upper lip (75%)
• Age: 7th decade
• Gender: female predilection
• Symptoms: slow growing mass
• Multifocal
Treatment
• Conservative surgical excision
• Enucleation not recommended
Prognosis
• Excellent
• Rare recurrence • Can be misdiagnosed as a malignancy

27. Basal Cell Adenoma
• Benign salivary gland neoplasm
• Monomorphic adenoma
• Incidence: 2% of salivary gland tumors
• Site: parotid gland (75%)
• Age: 4-9th decades
• Gender: female predilection (2:1)
• Symptoms: slow growing mass (< 3cm)

28.  Basal cell adenoma has 3 types histologically:
 SOLID- Most common with Solid nests of tumor cells and are with Uniform,
hyperchromatic, round nuclei, indistinct cytoplasm with Peripheral nuclear palisading
and Scant stroma
 TRABECULAR- Elongated anastomosing cords of basal cells, surrounded by connective
tissue stroma
 TUBULAR -Basaloid cells surrounds the duct like structure.
 Membranous or dermal analogue adenoma--Tumor islands moulded in jig saw puzzle
fashion surrounded by hylinized basal lamina
 Treatment
• Complete surgical excision
 Prognosis
• Excellent
• Recurrences may occur • Malignant transformation is rare

29. Malignant Epithelial Tumors
Mucoepidermoid carcinoma – 29%
Adenocarcinoma, NOS – 27%
Acinic cell carcinoma – 17%
Polymorphous low grade carcinoma – 19.6%
Adenoid cystic carcinoma – 7.5%
Basal cell adenocarcinoma – 2.9%
Epithelial myoepithelial carcinoma – 1%
Clear cell carcinoma – 1%
Salivary duct carcinoma – 0.5%

30. MALIGNANT SALIVARY GLAND TUMORS
• Shorter duration than benign
• Grow rapidly or history of slow growth with sudden rapid activity
• Fixed to surrounding tissues
• Overlying skin or mucous membrane may be ulcerated or inflamed
• Surface talengectasia
• Parotid gland tumors associated with facial nerve paralysis or
neurological symptoms
• Regional lymph nodes may be enlarged
• Palate and retromolar gland tumors infiltrate bone,produce
radiolucencies and loosening of teeth

31. MUCOEPIDERMOID CARCINOMA
• Malignant epithelial salivary gland tumor
• 2nd most common salivary gland tumor
• 30% of malignant salivary gland tumors
• Age: 2nd – 7th decades
• Gender: slight female predilection
• Site: parotid gland, palate
• Etiology: radiation exposure
• Asymptomatic swelling
Gross pathology
• Well-circumscribed to partially encapsulated to unencapsulated
• Solid tumor with cystic spaces

32. HISTOLOGY—
Low-grade
• Mucus cell > epidermoid cells
• Prominent cysts
• Mature cellular elements
Intermediate- grade
• Mucus = epidermoid
• Fewer and smaller cysts
• Increasing pleomorphism and mitotic figures
High-grade
• Epidermoid > mucus
• Solid tumor cell proliferation

33. Treatment
Influenced by site, stage, grade
Stage I & II :-Wide local excision
Stage III & IV Radical excision +/- neck dissection +/- postoperative radiation
therapy
PROGNOSIS
• Recurrence
• Metastasis
– lymph nodes, lung, bone, skin
• Low to intermediate grades •
– good prognosis ( 90% 5 year survival )
• High grade •
– poor prognosis (40% 5 year survival)
• Site: submandibular, floor of mouth, tongue

34. ACINIC CELL CARCINOMA
• 2nd most common parotid and pediatric malignancy
• 5th decade
• F>M
• Bilateral parotid disease in 3%
• Presentation • Solitary, slow-growing, often painless mass
GROSS PATHOLOGY
• Well-demarcated
• Most often homogeneous

35. HISTOPATHOLOGY
• Circumscribed
• Variable growth patterns
• Variable cytology
• Low grade tumor
• Scant stroma
• Lymphoid infiltrate
TREATMENT:
- surgical excision
PROGNOSIS:
- low-grade malignancy - 12% recur
- 8% metastasize
- 6% mortality
- prognosis is better for minor gland tumors

36. ADENOID CYSTIC CARCINOMA
• Overall 2nd most common malignancy
• Most common in submandibular, sublingual and minor salivary glands
• M = F
• 5th decade
• Presentation
• Asymptomatic enlarging mass
• Pain, paresthesias, facial weakness/paralysis
GROSS PATHOLOGY:
• uncapsulated firm solid tan mass
• Histology:
• highly infiltrative
• small hyperchromatic cells
• cribriform (“Swiss cheese”), tubular, solid
• mucohyaline stroma
• Perineural invasion

38. TREATMENT
Complete local excision
Tendency for perineural invasion: facial nerve
sacrifice
Postoperative Radiations
Prognosis:
Local recurrence: 42%
Distant metastasis: lung
Indolent course:
5-year survival 75%,
20-year survival 13%

39. POLYMORPHOUS LOW GRADE ADENOCARCINOMA
• 2nd most common malignancy in minor salivary glands
• 7th decade
• F > M
• Painless, submucosal mass
• Morphologic diversity
• Solid, glandular, cribriform, ductular, tubular,
trabecular, cystic
HISTOLOGY
• Isomorphic cells, indistinct borders, uniform nuclei
• Peripheral “Indian-file” pattern
TREATMENT
• Complete yet conservative excision

40. Lymphoepithelial Carcinoma
• Rare
• High grade/poorly differentiated carcinoma
• Lymphoid stroma
• Asians, Greenlanders
• Epstein-Barr virus
• Prognosis – guarded
SALIVARY ADENOCARCINOMA NOS
• Some tumours still defy the current classification of salivary gland tumours ,
These are labelled as Salivary Adenocarcinoma Not Otherwise Specified (NOS)
TREATMENT & PROGNOSIS
• Early stage, well differentiated tumours appear to have a better prognosis
• The survival rate is better for tumours of oral cavity as compared to tumours of
major salivary gland

51. 1.Frey’s syndrome
1. Also called as auriculo-temporal syndrome
2. Occurs due to damage to the autonomic innervation of the salivary gland
3. Inappropriate regeneration of parasympathetic fibers
4. Stimulation of sweat glands of overlying skin with stimulus of salivation
Causes : ◦ Surgery of the parotid gland
◦ Injury to parotid gland
Clinical features : sweating and erythema at the site of parotid surgery by smell or
taste of food.
Investigation : ◦ Starch iodine test : ◦ After painting the area with iodine Starch applied
over the area becomes blue on gustatory stimulus
.
Prevention Sternomastoid muscle flap Temporalis fascial flap Artificial
membranes Form a barrier between skin and parotid bed to minimise inappropriate
regeneration of autonomic nerve fibres.
Treatment Initially conservative management Most recover in 6 months Anti-
perspirants Denervation by tympanic neurectomy Injection of botulinum toxin into the
affected skin.