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CASE PRESENTATION SUBMANDIBULAR TUMOR

CASE PRESENTATION SUBMANDIBULAR TUMOR Compiled by: Azizah Fitriayu Andyra (1102014055) Advisory Lecturer: dr. Herry Setya

Compiled by:

Azizah Fitriayu Andyra

(1102014055)

Advisory Lecturer:

dr. Herry Setya Yudha Utama, Sp.B, M.H.Kes, FInaCS

Clinical Rotation in Department of Surgery Arjawinangun Regional General Hospital Faculty of Medicine YARSI University

2019

CASE PRESENTATION

I. IDENTITY Date of Hospital Entry: February 4th 2019

Name

: Mr. S

Age

: 38 years old

Gender

: Male

Occupation

: Labore

Address

: Kaliwedi

Religion

: Moslem

Marital Status

: Single

II. ANAMNESIS Main Complaint Lumps on the right neck since ± 1 month before admitted to the hospital

Current Medical History Mr. S, 38 years old, came to Arjawinangun Regional Public Hospital to complained about lumps on the right neck that arose and began to swell since 1 month before admitted to the hospital. There is only one lumps initially, but then it multiplied and now there are two. The lumps getting bigger as time goes by and became the size of a pebble. Lumps also accompanied by pain and interfered with swallowing which disturbed the process of eating and drinking. Patient admit that the lumps cause difficulty in speaking and salivating more than usual. Patient deny the presence of redness, swollen and warm sensation. Patient has lose some weight, had fever, and sweating especially in the night. Patient had surgery on 6th February 2019. At this time, patient felt a slight pain due to a surgical suture.

Past Medical History Patient deny of having these symptoms in the past. Patient has consume treatment for lung disease for a month.

Family Medical History There is no family member with the same condition or complaint as patient

III. `PHYSICAL EXAMINATION

a.

Generalized Status General Condition Awareness Blood Pressure Pulse Respiratory Temperature

: Mild pain : Composmentis : 110/70 mmHg : 78 x/minute, reguler : 20 x/minute : 37,4 0 C

Head

Form

: Normocephale

Hair

: Black, hairfall (-)

Eyes

: Anemic conjunctiva (-/-), icteric sclera (-/-), light

Ears

reflexes (+/+), isochore pupil right = left : Normal form, cerumen (-), tympanic membrane

Nose

intact : Normal form, septum deviation (-), epistaxis (-/-)

Mouth

: Normal

Neck Trachea in the middle

Pulmonary

Inspection

: The chest is symmetrical both left and right

Palpation

: Vocal and tactile fremitus are symmetrical, crepitation (-),

Percussion

tenderness (-), rebound tenderness (-) : Resonant sound in both lung fields

Auscultation

: Vesicular and bronchial sound in the entire lung field, rhonchi (+/+), wheezing (-/-)

Cor

Inspection

: Ictus cordis is not appear

Palpation

: Ictus cordis is palpable on the 5th intercostal space, left

Percussion

midclavicular line : Right border of the heart is on the 4th intercostal space,

Auscultation

right parasternal line Left border of the heart is on the 5th intercostal space, left midclavicular line Top left border of the heart is on the 2nd intercostal space, left parasternal line : Regular S1 and S2 , murmur (-), gallop (-)

Abdomen

Inspection

: Flat, symmetrical, mass (-)

Auscultation

: Intestine sound (+)

Palpation

: Tenderness (-), rebound tenderness (-)

Percussion

: Tympani sound in four quadrants of abdomen

Upper extremities Muscle tone Movement

: Normal : Active / active

Mass

:

- / -

Strength

: 5555 / 5555

Oedema

:

- / -

Lower extremities

Muscle tone

: Normal

Movement

: Active / active

Mass

:

- / -

Strength

: 5555 / 5555

Oedema

:

- / -

b. Localized Status

Regio

Inspection: The surgical scar is covered by wound dressings

: Neck

IV. LABORATORY EXAMINATION Date : 4th February 2019

     

Reference

Test

Result

Unit

Value

HEMATOLOGY

Haemoglobin

10.9

(L)

g/dL

13.2-17.3

Leukocyte

16.0 (H)

10^3μL

3.8-10.6

Trombocyte

471 (H)

10^3μL

150-440

Hematocrite

33.4

(L)

%

40-52

Erithrocyte

3.87

(L)

10^6μL

4.4-5.9

MCV

86.3

fL

80-100

MCH

28.2

Pg

26-34

MCHC

32.6

d/dL

32-36

RDW

13.7

%

11.5-14.5

MPV

5.9 (L)

fL

7.0-11.0

BLOOD COUNT (DIFF)

 

Segment

   

28.0-78.0

Limphocyte

94.3 (H)

 

% 25-40

Monocyte

3.4

(L)

 

% 2-8

Eosinophil

1.9

(L)

 

% 2-4

Basophil

0.3

 

% 0-1

Luc

0

 

% 3-6

COAGULATION

Clotting Time

3

minutes

2 6

Bleeding Time

1’30”

minutes

1 3

CLINICAL CHEMISTRY

 

Random blood glucose

109

mg/dL

75 140

IMMUNOLOGY

Quantitative HBsAg

0.01

S/CO

Negative < 0.13

Anti HIV

Non reactive

 

Non reactive

Chest X-Ray Date : 11th December 2018 Semiopaque infiltrate at dextra superior lobe, air bronchogram (+) Tapered costophrenicus angle Cor: CTR <0.5 Diaphragms has smooth rounded contour Bone structures are intact Impression: Superior dextra lobar pneumonia dd/lung mass

V. DIAGNOSIS Submandibular tumor

VI. DIFFERENTIAL DIAGNOSIS Tuberculous lymphadenitis

VII. TREATMENT Kabiven intravenous fluid 25 drops/minute Parenteral Cefazolin 3x1 Parenteral Ketorolac 2x1 Parenteral Ranitidine 3x1 Oral TB regimen Chemotherapy

VIII. PROGNOSIS Quo ad vitam Quo ad sanationam Quo ad fungsionam

: dubia ad bonam : dubia ad bonam : dubia ad bonam

LITERATURE REVIEW

A. SALIVARY GLANDS ANATOMY Salivary glands serve to produce saliva, a fluid found in the mouth and throat. Saliva contains enzymes that serve to help digest food. Saliva also serves to block the occurence of infection in the mouth and throat. There are two kinds of salivary glands, namely the major salivary glands and minor salivary glands.

Major Salivary Glands

glands and minor salivary glands. Major Salivary Glands Parotid gland is the largest salivary gland with

Parotid gland is the largest salivary gland with the size of 5.8 x 3.4 cm. 80% of these glands are located above m. Masseter and mandible, another 20% in retromandibula. The parrot tail is located at the top ¼ m. Sternocleidomastoideus and extends to the mastoid process. The parotid gland is connected to the oral cavity through the Stensoni ducts and empties into the buccal mucosa as high as the upper two molars. The cranial nerve VII (facial nerve) that functions motorically for the facial muscles, enters the parotid gland and divided into 2 surgical zones (superficial and deep lobes). This facial nerve in the parotid gland branches into 5, namely: the temporal branch to the frontal muscle; branch of zygoma to muscle orbicularis oculi; buccal

branches to the facial muscles and upper lip; mandibular branches to the muscles of the lower lip and chin; the cervical branch to the platisma muscle. The auriculotemporal nerve, which is a branch of the mandibular nerve, runs parallel to the superficial temporal artert and vein. This nerve carries parasympathetic fibers to the parotid if the injury will result in Frey’s syndrome. This nerve also causes the spread of malignant parotid tumors to the cranial and intracranial bases through its perineural sheath (Suyatno and Emir TP, 2010). The arteries adjacent to this gland are the external carotid artery, the internal maxillary and the superficial temporalis. The drainage is through the deeply located retromandibular vein of the facial nerve. While the lymphatic drainage through the lymph nodes located within the parotid and paraparotid (Tjakra, 2010).

located within the parotid and paraparotid (Tjakra, 2010). The submandibular glands weigh half of the parotid

The submandibular glands weigh half of the parotid gland. Located within the submandibular triangle formed by m.anterior and posterior digly of the belly and the inferior edges of the mandibular ramus. The facial nerve of the mandibular marginal branch runs superficially from these and inner glands of m. Platisma. The submandibular duct (Wharton’s duct) exits the medial surface of this gland and runs between the m. Milohioid (lateral) and hioglossus and to m. Genioglossus. This duct enters the lateral oral cavity of the lingual frenulum. The lingual nerve feels

around Wharton’s, while the parallel hypoglossal nerve with the ducts, runs inferiorly from the ducts (Suyatno and Emir TP, 2010).

runs inferiorly from the ducts (Suyatno and Emir TP, 2010). The artery that enters the submandibular

The artery that enters the submandibular gland is the submental branch of the facial artery (the branch of the external carotid artery). The drainage is through a facial vein, which passes through the lateral surface of this gland. Lymphatic drainage runs to the deep cervical lymph nodes and jugular chain (Suyatno and Emir TP, 2010). The sublingual gland, the most minor salivary gland. Located below the basic mucosa of the mouth between the mandible and m. Genioglossus. The inferior part is m. Mylohioid. The Wharton’s duct and the lingual nerve pass through the sublingualis and m. Genioglossus. This gland lacks a capsule, unlike the parotid gland and the submandibular gland. This glans also lacks the dominant duct, its drainage through approximately 10 small ducts (Rivinus duct) and empties into the sublingual creases at the floor of the mouth (John and Harri, 2007). The artery supplying this gland is the sublingual branch of the lingual artery and the submental branch of the facial artery. Lymphatic drainage leading to the submandibular lymph nodes (Suyatno and Emir TP, 2010).

Minor Salivary Glands The minor salivary gland is a gland different from the major salivary

Minor Salivary Glands

The minor salivary gland is a gland different from the major salivary glands,

i.e. has no duct. The minor salivary glands are concentrated in the buccal, labial,

palatal and lingual regions. Minor salivary glands may also be found in the upper

pool of tonsils (Weber’s gland), tongue base (von Ebner’s gland), paranasal sinuses,

larynx, trachea and bronchi. Most of these glands are present in palate, upper lip

and cheeks. Most minor salivary glands receive innervation from the lingual nerve,

except for glands in the palate that receive the innervation of the palatine nerve

(Kuppersmith, 1995).

B. EPIDEMIOLOGY

The salivary gland neoplasm is a benign or malignant neoplasm derived

from the salivary gland epithelium, either the major or minor salivary gland.salivary

gland cancer is 5-7% of all malignancy heads and in the United States there are

2000 to 2500 new sufferers per year, whereas in Indonesia the incidence rate is unknown. 85% of salivary gland tumor are present in the parotif gland (the largest salivary gland) and 75% are benign tumors which are mostly pleiomorphic adenomas (benign mixed tumors) and with a smaller incidence of a monomorphic adenoma (Wartin’s tumor). While the other major salivary glands such as the submandibularis salivarius gland are 50% incidents as malignant/cancerous tumors and in subllingual sublosts almost all are malignant/cancerous (Tjakra, 2010). It was said to be the etiology of salivary gland cancer is exposure to radiation especially the type of mucoepidermoid carcinoma. While adenocarcinoma which occurs in the nasal cavity or sinus paranasales (especially sinus ethmoidalis) is associated with exposure to wood dust and is often found in wood industry workers (Tjakra, 2010). The incidence of salivary gland cancer continues to increase with age and the incidence of this cancer in patients <16 years is 2% (Futran et al, 2009). The likelihood of exposure to male salivary glands is equal to female. It is rare in children but the frequency of malignacy is more common in children. Approximately 35% of salivary gland tumors in children are mallignant, the most common type is mucoepidermoid carcinoma. Tumor or cancer of the salivary gland is often correlated with gender, which results from no predilection of sexual data except in monomorphic adenoma (Warthin’s tumor) found five times in men (Tjakra, 2010).

C. CLASSIFICATION OF TUMOR Clinical stage determination was established on the basis of TNM (Tumor, Nodule, Metastase) from AJCC (American Joint Committee on Cancer) in 2002, with revisions that have been made several times. This is due to new technology in the diagnosis and staging of cancer, the presence of new painting techniques with monoclonal antibody and molecular biology technique (PCR/RT-PCR). The proposed TNM classification is in tumor/malignancy of the parotid salivary gland, which can also be used in other salivary gland malignancy.

Tumor (T)

TX

Primary tumor cannot be assessed

 

T0

No evidence of primary tumor

 

Tis

Carcinoma in situ

 

T1

Tumor ≤2 cm in greatest dimension without extraparenchymal extension*

 

T2

cm extraparenchymal extension*

Tumor

>2

but

not

more

than

4

cm

in

greatest

dimension

without

T3

Tumor >4 cm and/or tumor having extraparenchymal extension*

 

T4

Moderately advanced or very advanced disease

 

T4a

Moderately advanced disease Tumor invades the skin, mandible, ear canal, and/or facial nerve

 

T4b

Very advanced disease Tumor invades skull base and/or pterygoid plates and/or encases carotid artery

*Extraparenchymal extension is clinical or macroscopic evidence of invasion of soft tissues. Microscopic evidence alone does not constitute extraparenchymal extension for classification purposes.

Nodes (N)

NX

Regional nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension and ENE (-)

N2

Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension and ENE (-); or metastases in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension and ENE (-); or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N2a

Metastasis in a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension and ENE (-)

N2b

Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N2c

Metastasis in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N3

Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-); or metastasis in any node(s) with clinically overt ENE (+)

N3a

Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-)

N3b

Metastasis in any node(s) with clinically overt ENE (+)

 

Pathological N (pN)

NX

Regional lymph nodes cannot be assessed

N0

No regional lymph node metastasis

N1

Metastasis in a single ipsilateral lymph node ≤ 3 cm in greatest dimension and no extranodal extension (ENE [-])

12

N2

Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE (+); or a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension and ENE (-); or metastases in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension and ENE (-); or in bilateral or contralateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N2a

Metastasis in a single ipsilateral lymph node, 3 cm or smaller in greatest dimension and ENE (+); or a single ipsilateral lymph node > 3 cm but not more than 6 cm in greatest dimension and ENE (-)

N2b

Metastasis in multiple ipsilateral lymph nodes, none > 6 cm in greatest dimension and ENE (-)

N2c

Metastasis in bilateral or contralateral lymph node(s), none > 6 cm in greatest dimension and ENE (-)

N3

Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-); or in a single ipsilateral node > 3 cm in greatest dimension and ENE (+); or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE (+); or a single contralateral node of any size and ENE (+)

N3a

Metastasis in a lymph node > 6 cm in greatest dimension and ENE (-)

N3b

Metastasis in a single ipsilateral node > 3 cm in greatest dimension and ENE (+); or multiple ipsilateral, contralateral, or bilateral nodes, any with ENE (+); or a single contralateral node of any size and ENE (+)

Distant Metastasis (M)

cM0

No distant metastasis

cM1

Distant metastasis

pM1

Distant metastasis, microscopically confirmed

Prognostic Stage Groups

Stage

 

T

 

N

M

0

Tis

N0

M0

I

 

T1

N0

M0

II

 

T2

N0

M0

III

 

T3

N0

M0

T0T3

N1

M0

IVA

T4a

N0N1

M0

T0T4a

N2

M0

IVB

T

Any

N3

M0

T4b

N

Any

M0

IVC

T

Any

N

Any

M1

13

Stadium histopathology WHO (Tjakra, 2010) Benign

1. Pleomorphic adenoma (Benign Mixed Tumor)

2. Monomorphic adenoma

3. Papillary cyst-adenoma lymphomatous (Warthin’s Tumor)

Malign

1.

2.

3.

4.

5.

6.

7.

Lymphoma

Mucoepidermoid carcinoma

Acinic cell carcinoma

Adenoid cystic carcinoma

Adenocarcinoma

Epidermoid carcinoma

Small cell carcinoma

8. Malignant mixed tumor

9. Carcinoma ex pleomorphic adenoma

D. RISK FACTORS Patient diagnosed with this disease is usually between the age of 50 and 60 years old. Radiation exposure also affect the possibility to increase the risk of salivary gland tumors especially in patients undergoing treatment with radiation in the head or neck area. Those who are working in places where there is radiation exposure also increased the risk of salivary gland tumors. In patients with previous family history has a higher risk for salivary gland tumors (John and Harri, 2007)

E. DIAGNOSIS

Anamnesis

1. Lumps

of

the

sublingual)

parotid,

submandibular

and

oral

mucosal

glands

(palate,

2. A lump in the parotid gland is usually located pre-auricular, causing the ears to rise, pain or not (associated with N. Trigeminal), the presence or absence of bell’s palsy associated with parotid malignancy

3. Paralysis n. Fascialis is present in approximately 2-3% of parotid malignancies

4. Dysphagia, throat pain and hearing loss are associated with malignant profundus lobes with extension to the oropharynx

5. Paralysis n. Glossopharyngeus, n. Vagus, n. Hypoglossus, n. Accesories, truncus sympathicus (Horner’s Syndrome) associated with parotid malignancy with extension on the nerve

6. The presence of lymph nodes of the neck enlargement, especially at levels I, II, and III are usually associated with malignant metastases derived from salivary glands

7. Progression of disease, the rate of growth associated with malignant grading and tumor size (cancer cells doubling time)

8. Risk factors, exposure to radiation and exposure to radiation and exposure to leather plant waste or sawdust

Physical Examination

1. Generalist status (examination from head to foot and vital signs)

2. General state (anemia, icterus, cough/shortness of breath, paresus of the extremities)

3. Performance status (Karnofsky Score)

4. Metastatic signs of lymph nodes, lungs, liver, bone or vertebrae

5. Local status

1. Inspection: the location of the tumor, the shape of the tumor, surrounding organs and the condition of the skin or mucosa above the tumor. On the neck, lifted ear lobules/lobules, lymph nodes enlargement. Intra oral such as blockage of the Stensen’s duct (stone, stricture), mucosal bulge in the

parapharyngeal area or tonsil/uvula cramps

2. Palpation: bimanual palpation is performed to assess the consistency, surface, mobility, size, limit and tenderness. Also the function of n. VII, VIII, IX, X, XI, XII 6. Regional status, palpation of lymph nodes neck at all levels, especially at all levels especially upper level (level I, II, III), both ipsilateral and contralateral. If there is an enlargement determine the location level, the largest size of lymph nodes, the number and mobility.

If there is an enlargement determine the location level, the largest size of lymph nodes, the

Investigations Radiological Examination

- Plain jaw image to determine whether or not the jaw bone (mandibular/maxilla) is involved in the malignant process of this salivary gland

- To perform a differential diagnosis of jaw bone cyst, jaw bone malignancy (Ewing Sarcoma, osteosarcoma) and salivary gland tumors (parotid and submandibular)

- Sialography, made when there is a differential diagnosis of parotid cyst or submandibular cyst. This examination is needed to see the image of the Stenson’s duct and its branches. With sialography can be seen there is narrowing or blockage of the duct, the shadow of the narrowed and fibrotic. Can also be seen whether the duct structure is pushed or not by a tumor mass. Radiological examination for staging

- Chest X-ray to see pulmonary metastases

- Abdominal ultrasound CT-Scan/MRI

- Especially for large salivary gland tumors with limited mobility

- Important for surgical and operability approaches e.g. in parotid tumors of the profundus lobes and extension into the oropharynx

- Metastases on neck lymph nodes, extension, sometimes to see extracapsular extension Biopsy

- FNAB, not yet a standard check, its accuracy varies (60-90%).

- Frozen cut, on operative specimens for operable tumors. In parotid tumors, frozen cuts are performed from superficial parotidectomy specimens, submandibular tumors and minor salivary glands from excision specimens

- Excisional biopsy, recommended for sublingual tumors and small salivary gland tumors, is performed in the form of definitive surgery (wide excision). When an

inoperable tumor is performed and incisional biopsy. An incisional biopsy should be avoided in an operable tumor to prevent tumor spillage, tumor damage and facial nerve injury.

F.

MANAGEMENT For benign tumors, excision of the submandibular gland is for diagnosis and curative purpose and of course with frozen cut to confirm. If the frozen benign operation is completed and the malignancy is still continuing, the submandibular dissection (excision of lymphatic level I structure) and frozen are necessary. If the lymph nodes contain metastases, then it should be followed with radical neck dissection. The sequence of actions is performed when there is no clinical neck lymph node enlargement (N0). If no bone is involved with N0 extended supraomohyoid dissection includes removal of the glandular bed, muscles and nerves around it. If clinical lymph nodes are palpable, neck dissection is modified (Albar, et al, 2003). Neck dissection is performed when there is enlarged clinically naive (n- positive) lymph nodes. If there is mandibular infiltration, composite resection (mandibulectomy and one sided neck dissection) is performed. As with parotid tumors, removal of the hypoglossal nerve and lingual nerve is only done if the macroscopic has infiltrated the tumor and local extension to the surrounding tissue (e.g. the base of the mouth, tongue) requires a more radical excision (Suyatni and Emir TP, 2010).

Radiation Radiation as primary therapy is indicted in cases of inoperable salivary gland cancer and as post-operative adjuvant in high grading cancer or recurrence cases. Adenoid cystic carcinoma, high grade mucoepidermoid carcinoma, high grade adenocarcinoma, squamous cell carcinoma and lymph node metastases are the spesific cases requiring adjuvant radiation. Adjuvant radiation is also indicated in the tumors attached to the nerves (facialis, lingualis, hypoglossus and assesorius),

residual carcinoma, macroscopic or microscopic tumor residue and T3 or T4 stage cancer. In cases of recurrent or macroscopic pleomorphic adenomas, tumor spoillagr may be given post-operative radiation. As adjuvant radiation can decrease local recurrence and increase survival rate, local recurrence decreases from 54% to 14%. The dose of radiation on the primary tumor and covering the incision site is 50-70 Gy (Tjakra, 2010). Adjuvant radiation on post neck dissection is indicated in all high grade malignancy, T3 or T4 cancer stage, lymph node containing more than 1 metastase, and growth of capsule or lymph node with diameter over 3 cm.

Chemotherapy Chemotherapy cannot be used as a primary therapy for curative purposes in salivary gland salivary gland cancer. Data and research on the role of chemotherapy in cancer is still limited. Chemotherapy may be given as an adjuvant or palliative in metastatic cases. Response to chemotherapy generally ranges from 10-30%. Doxorubicin and 5-fluorouracil were inferred in response to a retrospective study (in adenoid cystic carcinoma) but were not proven prospectively. Cisplastin, paclitaxel, vinorelbin, epirubicin and mitoantrone averaged a response of 10-20% in prospective studies with metastatic or recurrent cancer samples. The combination of chemotherapy of chemotherapy containing cisplatin or anthracycline (cyclophospamide/doxorubicin/cisplatin/vinorelbin, cisplatin/5-FU) will increase the average response to 20-30% with tolerable toxicity (Tjakra,2010).

G. PROGNOSIS AND FOLLOW UP Prognosis In salivary gland cancer, overall 5 years survival is 70-90% at low grading and 20-30% in high grading tumors. Total recurrence and distant metastases vary from 15% to 20% and commonly occur in the perineural invasive carcinoma (adenoid cystic carcinoma). Survival 5 years on beingn tumors reaches 100%, high risk for recurrence in patients who get adequate surgery.

Byers, et al, reported the results of selective rafiation therapy on malignant submandibula tumors, the mean local control was 64% and the survival rate was 50%. Spiro in another research reported the results of surgery of 129 submandibular gland cancers with observations of at least 10 years of obtaining a 40% locoregional and the cause-specific cure rate for 5 and 10 years were 31% and 22%. The benign submandibular benign tumor operated in operated 106 patients and only 2 cases were recurrent (Albar, 2003)

Follow Up It is recommended every 3 months in the first 3 years after the therapy is completed, then every 6 months for 5 years and continued once a year for life. At the patient’s annual follow up, things that should be examined completly are:

physical, chest X-ray, abdominal ultrasound and bone scan to determine cancer- free patients or not. Information to look for at the examination is the length of life (in years and months), duration of tumor-free intervals, patient complaints, performance status, disease status (cancer free, residual, metastatic, cancer or new disease) and therapy including for its complication. In the adenoid cystic carcinoma that has the pitential to spread along the nerve and metastasize deep into the lungs, a careful imaging examination (MRI and thoracic photos) should be performed (Suyatno and Emir TP, 2010).

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Alber, Z., Tjindarbumi, D., et al. (2003). Protokol PERABOI. Bandung.

American Society of Clinical Oncology. (2011). Salivary Gland Cancer. Retrieved from: www.cancer.net/cancer-types/salivary-gland-cancer/risk-factor at 8 February 2019

Futran, N., Parvathaneni, U., et al. (2009). Malignant Salivary Gland Tumor, Head and Neck Cancer:; A Multidisciplinary Approach 3rd Ed. Philadephia:

Lippincott William & Wilkins

John, M. & Harri, P. (2007). Salivary Gland Neoplasm. Emory University Hospital:

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Kuppersmith,

R.

(1995).

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salivary

gland

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Department

of

Otolaryngology of Baylor College of Medicine

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Suyatno & Emir, T. (2010). Bedah Onkologi: Diagnosisi dan Terapi. Jakarta: CV Sagung Seto

Tjakra, W. (2010). Panduan Penalatalaksanaan Kanker Solid PERABOI 2010. Jakarta: CV Sagung Seto