salivary gland cancers management updates

1. Case Presentation on Salivary
Gland Tumors
By:Gebrekirstos,COR-II,AAU
Moderator: Dr Munir, Clinical Oncologist
May 28,2019

2. Outlines of presentation
• Case
• Investigations
• Staging
• Management
• Prognosis
• Complication of Rx
• Follow up
• Case critics
• References

3. Investigation modalities
1) Hx & PE with emphasis to fixation and LAP
2)U/S in combination with FNAC-1st Dxtic step for
superficial parotid, submandibular, sublingual &
cervical LN.
-U/S features ca=ill-defined borders,heterogonous
architecture, internal necrosis & cystic changes
US -highly sensitive ≈100 % similar to CT scan
- low-cost modality
-Differentiate intra- & extra glandular lesion

4. Investigation modalities
3) MRI -sensitivity - 87 %
-specificity - 94 %
• particularly useful in:
-visualizing the tumor interface and surrounding tissues
for a correct surgical planning, especially in case of
larger tumors (more than 4 cm),
-tumors arising in deep structures or involving them
• Advantages of MRI on CT,
-elimination of dental artifacts
-distinguish b/n a tumor and obstructed secretions

5. Investigation modalities
• 4) 18F-FDG-PET/CT is not employed for staging
at diagnosis in case of low-grade histotypes.
• Could be useful in intermediate & high-grade
tumor for surgical planning.

6. Investigation modalities
5) Histological diagnosis –indication:
-Evidence of malignancy has been assessed
- Surgery(neck dissection& parotidectomy
needed).
• Fine-needle aspiration biopsy (FNAB) is the
preferred method .
• Avoided open biopsy b/c risk of seeding.

7. Staging

8. Management
• should receive an individualized treatment, more
than any other cancer patients.
• For this reason, experienced clinicians are
particularly important.
• Pre treatment evaluation
-Dental evaluations
-Nutritional assessment
-TFT
-Speech evaluation

9. MDT!

10. Management options
• Surgery
• Adjuvant RT
• Chemoradiotherapy
• Definitive RT
• Chemotherapy
• New Rx(hormonal deprivation treatment
tyrosine-kinase inhibitors)

11. Surgical management
• Surgery of primary tumor is treatment of
choice for both major & minor SG tumors.
• Surgical technique depends:
-location
-extent of primary disease
-regional LN
• Clinically +ve LN, neck-neck dissection along
with the resection of the primary tumor.

12. Surgical management
• Aggressive surgery does not improve DFS
• Preservation of the facial nerve, at least
partially, followed by PORT.
• Adjuvant PORT has no negative effect on facial
nerve function.

13. Surgical management
• Both benign and malignant neoplasm may be
approached by the similar surgical techniques.
• Tumor must be resected with normal tissue
margins surrounding the neoplasm.

14. Surgical management
• In parotid neoplasms, the diagnostic procedure of
choice is superficial parotidectomy with FN
preservation,& it is treatment of choice
superficial lobe malignancy.
• For large tumor with parapharyngeal space
extension:
1)superficial lobectomy is needed for the surgical
exposure of the deep lobe
2)Can also achieved by cervical approach, which
may be accompanied by submandibular gland
displacement or mandibulotomy.

15. Surgical management …

16. Neck -Surgical management
• The risk of LN met from parotid ca is generally low ,but it increases
in:
-high-grade
-advanced T-stage
-presence of extra capsular extension
-facial paralysis.
• In these cases, a selective prophylactic neck dissection, including
levels IB, II, and III, may be appropriate.
• LN +ve requires conventional neck dissection including levels IB, II,
III, IV, and VA.
• If RT is to be used postoperatively, elective neck dissection is less
important given the equivalency in elective treatment.

17. Neck -Surgical management
• Decision to treat the neck for parotid tumors
will be indicated by a score of at least 4

18. Neck -Surgical management

19. Neck -Surgical management

20. Adjuvant therapy
-Can be :
• PORT
• POCCRT
-03 basic RT approaches are used:
1)Conventional
2) 3DCRT planning procedure
3)IMRT

21. Adjuvant RT
• Improves loco regional control following Sx.
• Indication :
-High- grade tumors
-Advanced-stage tumor (T3/T4)
-Close(≤5 mm) margin
-Microscopically +ve surgical margins
-Neck node met
-Bone involvement
-PNI
-Recurrent cancer
-Deep lobe of parotid ca
-Concern of surgeon over margin and tumor spillage irrespective of
histology
-Vascular & lymphatic invasion
-Extracapsular spread
-ACC
-Minor salivary glands
-sumandibular & sublingual gland ca

22. Adjuvant RT

23. Neck RT
• Elective neck RT prevents LN relapses in a
selected group of pts.
• General not indicated for acinic cell or ACC.
- Small primary lesions (pT1) completely excised
are at very low risk of failure after surgery
alone and could not benefit from adjuvant RT

24. Neck RT
• Definitive -cN+
-pN+
level I-V, dose,60Gy(+N),66Gy(Extra N)
• Elective =-advanced T stage
-certain histologic subtypes
-facial nerve dysfunction
-recurrent disease.
level IB-IV, dose 45-50 Gy

25. Adjuvant RT…

27. Adjuvant RT
• CTV delineation depends on disease extent
and pathologic findings after surgery.
• Mandatory to cover the whole surgical bed.
• Ipsilateral neck node levels I to V should be
included in case of pathologically pN+.
• PNI ,cranial nerve pathways up to base of the
skull must be included in the target volume

28. Adjuvant RT
• In a study of the Dutch Head and Neck Oncology
Cooperative Group on 498 pts, postoperative RT
improved significantly the 10-year LC compared with
surgery alone in
• Characteristics + RT vs Sx only
- T3–4tumors 84 % vs. 18 %
- close margins 95 % vs. 55 %
- incomplete resection 82 %vs. 44 %
- bone invasion 86 % vs. 54 %
- PNI 88 % vs. 60 %
- pN(+) 86 %vs. 62 %

30. Adjuvant CCRT VS RT - Hsieh et al.
SG-ACC 91 pts Rx
by Sx, (2000-2013) POCCRT=33
CT-cisplatin
PORT=58
Adjuvant Rx
LRC-5yr=84%
8yr=79%
DM=34%,17 pts
LRC-5YR=97%
8yr=97
DM=14 pts
Dose 66Gy, FU-71 Mon,
p=.066
DM-FS,DFR,OS-comparable
Conclusion=,in SG-ACC, adding CT to PORT improve LRC & Opoid requiring
Pain-FS , primarily in stage III & IV, +ve margin, PNI. But no d/ce in DFS, OS, DM-
FS.

33. Definitive RT
• can be the best treatment option in :
-Technically unresectable
-Medically inoperable tumor
Heavy-particle RT (proton & carbon ion therapy)
exert a higher activity in ACC.
• CTV is defined as GTV, macroscopic disease plus a
5-mm basic margin for all histology and sites.
• The base of the skull and the lymph nodes are
considered as the target volume

34. Definitive RT
• RT with neutrons has shown a higher LR
control (but not survival) than photon-based
conventional RT but with higher late effect.

35. Neutron vs photon as definitive Rx
RTOG-MRC
• Purpose –to compare fast Neutron RT to conventional
photon/electron RT in USA& UK.
• Methods-eligible criteria inoperable primary or
recurrent major/minor SG tumors(32 pts).
• Results-10 yrs FU
-LRC rate –neutron vs convensional=56%:17%
-OS-Neutron vs convensional=15%vs 25%
-Pattern of failure –DM(neutron),LRF(conventional)
• Conclusion-Fast neutron RT is treatment-of-choice for
inoperable primary/recurrent SG tumors.

37. Chemotherapy
• Indication:
- relapsed disease with
- metastatic disease palliative aim
• No randomized study to define best therapeutic choice
• No standard CT regimen
• Platinum- based CT has best response, as monotherapy
& combined regimen with doxorubicin in most cases.
• Not clear whether a combination CT has any
advantage over a single-agent CT

38. Chemotherapy …
• No benefit, in terms of survival in pts
responding to CT over non responders.
• So, CT should be reserved to symptomatic pts
& for rapid progressive diseases.

41. New treatment approaches
• Includes :
-Hormonal deprivation treatment
-Tyrosine-kinase inhibitors
• Are under evaluation.

42. New treatment approach …
• Androgen receptor is a pathogenetic factor in
SDC and represent a valid therapeutic target.
• Androgen deprivation therapy (ADT) is active
in AR-positive SDC and adenocarcinoma,NOS

46. Management of recurrent &
metastatic salivary gland ca
A)Local relapse-surgical salvage is the optimal
treatment for resectable recurrent SG tumors
• If surgery is not feasible, irradiation or, in
selected patients, reirradiation
B) Regional recurrence — Neck dissection, with
or without PORT

47. Management of recurrent &
metastatic salivary gland ca
C)METASTATIC DISEASE- common sites lung, liver
& bone.
Systemic therapy may be reserved for
symptomatic and rapid disease progression
for whom a local therapy
(RT/metastasectomy) is not appropriate.

48. Sequelae of therapy
• Facial nerve scarifies
• Neuroma of greater auricular nerve
• Salivary failure
• Frey syndrome
• xerostomia
• Trismus -RT induced fibrosis of TMJ/masseter muscles
• complications to auditory system(external canal
stenosis, hearing loss, decrease quality of life)
• eye complications (nasolacrimal duct obstruction,
cataract, retinopathy, perforated globe)

49. Prognosis
• Major salivary gland better Px than minor salivary gland
• Parotid ca better than submandibular ca
-Tumor site
-Histology subtype & grade
-Preoperative facial nerve dysfunction
-High primary tumor stage (T stage)
-Positive cervical lymph nodes
-PNI
-Positive surgical margins
-High tumor histology or grade
-Older age
-HER2/neu especially in SDC

51. fffff Re References

52. If not for the facial nerve parotid surgery would just be
a lipoma excision!!!
Thank you!

53. Questions?