SALIVARY GLAND TUMORS CLASSIFICATIONS DIAGNOSIS AND TREATMENT

1. DR.MAMOON AMEEN

2. Introduction

3. Classification
Benign
 Pleomorphic adenoma
 Warthin’s tumor
 Oncocytoma
 Lymphangioma
 Haemangioma
 canalicular adenoma,
 basal cell adenoma
 myoepithelioma
Malignant
• Mucoepidermoid carcinoma
• Adenoid cystic carcinoma
• Carinoma ex- pleomorphic adenoma
• Acinic cell ca
• Adenocarcinoma
• Salivary ductal carcinoma
• Squamous cell carcinoma
• Non-hodgkin’s lymphoma

4. EPIDEMIOLOGY
 2-3%of all head and neck neoplasms.
 Benign tumors account for 63% to 78% of all salivary gland neoplasms.
 (64%-80%), in the parotid glands ,malignancy (15%- 32%).
 7-11% occur in the submandibular glands, malignancy (37% - 45%).
 less than 1% in the sublingual glands, malignancy (70%-90%),
 9%-23% in the minor glands.

5. Rule of 80’s:
-80% of salivary gland tumors occur in the parotid
80% of parotid tumors are benign
-80% of parotid tumors are Pleomorphic adenomas
-80% of parotid Pleomorphic adenomas occur in the superficial lobe
-80% of untreated Pleomorphic adenomas remain benign

6. Etiologic Factors
 Radiation exposure
 Genetic predisposition
 Tobacco
 Chemical carcinogens
 Viruses

7. PLEOMORPHIC ADENOMA
 Most common of all salivary gland neoplasms
 80-90% of parotid tumors
 Of the minor salivary glands most commonly occurs in the
palate ,upper lip
 4th-6th decades
 M:F = 1:3-4

8. PLEOMORPHIC ADENOMA
 Slow-growing, painless , firm mass
 Encapsulated
 Mixed tumor: contains both epithelial and mesenchymal elements
 It sends pseudopod-like extensions ‘into surrounding tissue
 Malignant transformation is 10% if observed for more than 15 years.

9.  Because most of the tumors arise from the superficial lobe, a superficial
parotidectomy is often required.
 Recurrent pleomorphic adenoma is an uncommon but challenging problem.
 There are frequently multiple foci of recurrence that may continue to manifest
over several years.

10. Warthin’s tumor(papillary cystadenoma lymphomatosum )
 2nd most common after pleomorphic adenoma
 Commonly seen 7th decade
 Male: female (7:1)
 Associated with cigarette smoking
 Almost Exclusively in parotid gland Parotid tail
 10% bilateral

11.  Usually Fluctuant, slow growing
 Encapsulated cystic lesion
 Histologically: epithelial & lymphoid elements
 Never malignant
 Wide local excision
 parotidectomy with facial nerve preservation

12. Oncocytoma (oxyphil adenoma)
 Rare 1 % of benign salivary tumor
 6th decade
 No gender predilection
 Parotid ,Submandibular gland
 Minor salivary glands: palate, buccal mucosa,
 Slow growing ,painless
 The treatment of choice for is surgical excision.

13. Malignant neoplasms
 Shorter duration
 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 telangiectasia
 Nerve involvement
 Regional lymph nodes may be enlarged

14. Mucoepidermoid Carcinoma
 2nd most common salivary gland tumor
 Most common salivary gland malignancy
 Parotid 80% - 90% of cases
 Age: 5th – 7th decades
 Gender: slight female predilection
 Site: parotid gland, palate
 Etiology: radiation exposure

15.  It contain two major elements:
 mucin producing cells & epithelial cells of epidermoid variety & according to that classified into
Low grade
Intermediate
High grade
 Low-grade: slow growing, painless mass
 High-grade: rapidly enlarging, +/- pain

16. Adenoid cystic carcinoma(Cylindroma)
 2nd most common salivary gland malignancy
 Infiltrates widely into the tissue planes & muscles
 Perineural spread
 Commonly in submandibular gland, sublingual or minor salivary glands
 Slow growing but aggressive neoplasm with a remarkable capacity of recurrence.

17.  Infrequent cervical metastases
 High degree of late distant metastases
 Treatment
 Complete local excision
 Tendency for perineural invasion: facial nerve sacrifice
 Postoperative RT
 Prognosis
 Local recurrence: 42%
 Indolent course: 5-year survival 75%, 20-year survival 13%

18. ACINIC CELL CARCINOMA
 6% to 8% of all salivary malignancies
 Mostly in parotid
 3% Shows bilateral involvement
 Has a low-grade behavior
 Associated with the best survival rate of any salivary malignancy

19. ACINIC CELL CARCINOMA
 They seldom metastasize but they have high tendency to recur locally
 Primary treatment is complete surgical resection with neck dissection limited to the therapeutic
setting.
 Postoperative radiation is not routinely advised

20. Carcinoma ex-pleomorphic adenoma
 Malignant degeneration can occur in 3% to 7 % of
pleomorphic adenomas.
 Parotid > submandibular > palate
 Risk of malignant degeneration
 1.5% in first 5 years
 9.5% after 15 years
 Typical history of slowly growing mass demonstrating sudden increase in
the growth.

21.  Treatment
 Radical excision
 Neck dissection (25% with lymph node involvement at presentation)
 Postoperative XRT

22.  Polymorphous Low-Grade Adenocarcinoma
 2ND most common malignant intraoral tumor of the salivary glands.
 Palate (60-70%) > buccal mucosa (16%) > upper lip, retromolar area,
base of tongue.
 F:M = 2:1 & common in 5th to 7th decade.
 A painless mass in the palate is the most common presentation.

23. SALIVARY DUCT CARCINOMA
 High grade aggressive tumor
 from excretory duct cells in major salivary gland mainly
 Microscopic feature remarkably similar to mammary intraductal carcinoma
 35% recurrence
 62% distant metastasis
 Neural invasion and extraglandular extension are commonly seen.
 Most patients die within three years.

24. SALIVARY DUCT CARCINOMA

25. ADENOCARCINOMA:
 Ranging from low grade well differentiated to high grade invasive lesions
 Common in major glands
 Originate from excretory or striated ducts
 Cystic or solid, may be papillary or non-papillary in growth pattern
 Prognosis depend on grade

26. SQUAMOUS CELL CARCINOMA
 Rare to be primary & common to be secondary from intraparotid lymph node or direct
involvement
 Should be differentiated from mucoepidermoid carcinoma by presence of mucin on
electronmicroscope with stain or immunohistochemical test
 Incidence 0.3% -1.5% in major gland 50% nodal metastasis
 M:F = 2:1
 7th-8th decades
 TR: Surgery + Neck dissection + Postop. RT

27. LYMPHOMA:
 5% of all extranodal lymphoma affect salivary gland
 90% occur in parotid
 85% are N H L
 Its risk in Sjogren’s syndrome is 44 fold higher

28. SECONDARY TUMORS:
 The majority of metastasis are caused by lymphatic spread from cutaneous
malignancy of the head & neck
 Hematogenous metastasis are rare & majority from lung, kidney & breast
 Contiguous extension of facial sarcomas
 10% of malignant parotid gland tumors
 40% are SCC, & 40% are melanoma

29. STAGING

30. STAGING:
Stage I T1N0M0
Stage II T2N0M0
Stage III T3N0M0 or T1-3 N1M0
Stage IVA T4aN0-1M0 or T1-4a N2M0
Stage IVB T4bNxM0 or TxN2-3M0
Stage IVC TxNxM1

31. Evaluation of patient
History Important points in the history
 Mass (duration, rate of the growth, presence of pain)
 Facial paralysis, B/L
 Cervical lymphadenopathy
 Eyes and joints symptoms
 H/O exposure to radiation
 Ipsilateral weakness or numbness of tongue

32. Examination:-
 Size of the mass
 Overlying skin, Skin fixation, mobility
 Lymphadenopathies
 Cranial nerves
 Intraoral examination

33. Investigations
 USG
 X ray chest
 OPG To R/O mandibular involvement.
 CT SCAN
 MRI

34. USG
 Distinguish intrinsic from extrinsic tumors
 It can be used to differentiate solid from cystic masses in the salivary glands
 USG guided FNAC

35. CT/MRI
 Anatomical localization
 Local, regional ,distant invasion
MRI IS BETTER ??
 Excellent assessment of margins
 Deep extension and infiltration
 Bone marrow invasion
 Perineural spread
 Intracranial extension

40. Fine-Needle Aspiration Biopsy
 Accuracy well established
 Sensitivity = 54-95%
 Specificity = 86 - 100%
 Confirms possibility
 Lymphoma/inflammatory masses.
 Allows preoperative assesment of
 Nature of tumour
 Extent of resection (conservative/radical)
 Management of facial nerve (high grade adenoid cystic)
 Likelihood of neck dissection (high grade).

41. Open biopsy
 Contraindicated
 Justified in minor salivary gland tumor
 Ulcerated lesion
 where fine needle aspiration cytology suggests lymphoma,
 In cases of diffuse salivary enlargement

42. Frozen section
 may be useful when
 preoperative FNA is non-diagnostic,
 when the FNA diagnosis is at odds with the clinical and/or intraoperative findings
 The results of frozen section may help in intraoperative decision-making. In cases where frozen
section shows high-grade carcinoma, the surgeon may proceed to perform at least a limited neck
dissection with the parotidectomy

43. MANAGEMENT
 TREATMENT
 Surgery
 Radiotherapy
 Chemotherapy
 Factors that influence treatment
 Age
 Metastatic spread
 Facial nerve involvement
 Mandibular / Temporal bone involvement
 Skin
 Site of tumor
 Size, Extent, Grade & stage

44.  Benign salivary gland tumors should be excised completely with an adequate margin to avoid local
recurrences
 Simple enucleation not appropriate treatment recurrence rate 21-45%
 1 cm margin has been shown to be adequate.
 Cutting into the tumour should be absolutely avoided as it can lead to tumor spillage
Surgery
Benign tumors

45. Surgery
Benign tumors
 Superficial parotidectomy
 partial superficial parotidectomy,
 Deep lobe tumors -Total parotidectomy with facial nerve preservation.
 Parapharyngeal tumors -cervical-parotid approach and with or without a mandibulotomy.

46. Surgery
Benign tumors
 A tumor of the submandibular gland requires submandibular gland resection
 If the tumor originates from a minor salivary gland, the tumor and a cuff of normal
tissue should be excised.

47. Surgery
Malignancies
 The mainstay of treatment for salivary carcinomas is surgical resection with or without postoperative
radiotherapy
 The extent of surgery is dependent on the size and site of the tumour
 The goal of surgical treatment is to achieve local control
 As a general rule, every effort should be made to preserve a nerve which was functioning normally
preoperatively

48. Surgery
Facial nerve sacrifice should be reserved for cases of
 preoperative paralysis,
 cases of recurrent malignancy
 gross encasement and infiltration of the nerve

49. Surgery
Parotid Gland:
 Size and location determine extent of resection
 Most T1/T2 lesions lateral to the nerve are suitable for a superficial parotidectomy with adequate
margin 1.5cm
 Larger and deep lobe tumours usually require a total conservative parotidectomy with preservation of
the facial nerve
 Patients with high grade and extensive disease (i.e. skin involvement or facial palsy) may require
extended radical parotidectomy

50. Superficial parotidectomy:
Removal of superficial lobe of the parotid
(superficial to facial nerve)

55. RADICAL PAROTIDECTOMY
 Removal of
 Both lobes of parotid
 Facial nerve
 Mandibular ramus
 Masseter muscle
 Infratemporal fossa dissection
 Subtotal petrosectomy

56. Complications of parotid surgery
 Facial nerve injury
 HEMATOMA
 Salivary fistulas
 Infection : Flap necrosis is common
 Frey’s syndrome
 Sialocele
 Numbness over the face and ear

57. Neck dissection
 Neck dissection should be performed in patients with clinical or radiological evidence of nodal disease
 A prophylactic selective neck dissection should be considered for patients with high-stage or high-
grade

58. Radiotherapy
 Primary treatment for salivary carcinomas is limited to unresectable tumours
 Postoperative radiotherapy is indicated for:
 Tumours greater than 4 cm,
 Presence of positive surgical margins or
 Facial nerve were preserved despite being adherent to the tumour,
 lymph node metastases
 High grade tumor
 perineural invasion.
 Recurrent pleomorphic adenoma
 Spillage after surgery for pleomorphic adenoma

59. Radiotherapy
 Preoperative radiotherapy
Given in large tumours to reduce the size and make it better operable, i.e. to down stage the disease

60. Prognosis
 Advanced stage, higher histologic grade _____poor prognosis
 submandibular location _____________________poorer outcome
 10 yr survival rates for stage I ____82%
II____ 64%
III ____50%
IV ____33%
 Regional lymph node metastases ______poorer prognosis

61. Prognosis
 Distant metastases _________________ poor prognosis
 Parapharyngeal space extension _____poor prognosis
 Parotid malignancies ________________ better prognosis
 Facial nerve paralysis ________________ poor prognosis