Premanagement in Salivary Gland Tumors

Dr Sasikumar Sambasivam Click to edit Master subtitle style Moderator: Dr Nidhi Patni

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Anatomy

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Anatomy

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Anatom y

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Within the Parotid

tempor al

Zygomaticotemp oral Facial Nerve

External carotid A Retromandibular Vein Facial Nerve

Superficial temporal V Maxillary V

zygomat ic bucc al mandibul ar cervic al Superficial temporal A Maxillary A

Cervicofaci al

Post auricular V External jugular

P.Auricular A Common Facial V

Sub Mandibular gland

Sub Lingual gland

The Ducts

Relationship to Neural Str.

Major Gland
Parotid Superficial Deep Cranial Nerve Foramina of base of skull 7 9,10,11,12 Stylo mastoid foramen Jugular foramen and Hypoglossal canal

Sub mandibular

V3, Foramen ovale 7 (mand and cervical br.), Stylomastoid foramen 12 Hypoglossal canal

Sub lingual

V3

Foramen ovale

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The Saliva

Serous Viscous

(Parotid and Von Ebner) (Sublingual & Minor )

Mixed (Submandibular & Sublingual) Parotid-25 % of total saliva secretion Submandibular-60% Sublingual-5%

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Cystatins, AntiHistatins, Bufferi Bacteri ng Mucins, Amylases, al Cystati Peroxidases Mucins, ns, Anti Digesti Lipase Mucins on Vira Saliv l Minera a Click to Antiedit Master subtitle style lFung Cystatins, Histati ization Histatins, al ns LubricatProlineTissue ion rich proteins, Coati &ViscoAmylases, Statherins Cystatins, Mucins, ng elasticity Mucins, Proline-rich proteins, 7/8/12 Statherins Statherins

Functions briefing Amylases,

Carbonic anhydrases, Histatins

Lymph Nodes of Parotid

Peri and IntraparotidLevel 1B,2,3, RP nodes; C/L nodes if T crosses midline

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Lymphatic Drainage of
Sub Mandibular

Level IB Level2Level 3

Sub Lingual

Level IA Level 1B- Level 2

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Epidemiolog y

3-4% of all H & N neoplasms In gen -Parotid>SubMandibular>SubLingual Parotid: 80% benign, Submandibular: 50% benign Sublingual : Most are malignant Age factor: Benign: 40 M>F; Malignant: 55yrs M=F 3% of all in Children ,half are malignant. 7/8/12

Aetiology

Unknown Radiation Induced(Modan et al) Nutritional deficiency(A &C) Infection EBV UV rays controversial Cigarettes ,Alcohol, hair dyes, higher educational level ? Ass. With Breast cancer(2.5 fold increase)
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Pathology

Benign:

Pleomorphic Adenoma Papillary Cystadenoma Lymphomatosum (Warthin Tumor) Benign Lymphoepithelial Lesions (Godwin Tumor) Oncocytoma Basal Cell Adenoma

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Pathology-Malignant HP types(WHO) carcinoma Acinic cell carcinoma Oncocytic

Mucoepidermoid Salivary duct carcinoma carcinoma Adeno ca Adenoid cystic carcinomaMyoepithelial ca Polymorphous LG adeno Ca in pleomorphic ca adenoma Epithelial-myoepithelial Squamous cell ca carcinoma Basal cell adenoca Small cell carcinoma Sebaceous ca Papillary cystadeno ca Mucinous adeno ca
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Gradin g

Low grade

Acinic cell ca Muco epidermoid (LG)

High grade
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Mucoepidermoid(HG) ca Adeno ca / PD/Anaplastic Malignant Mixed Adenoid Cystic Lymphoepithelioma(Eskimoma)

TYPE

Parotid (n = 1778 cases) Mucoepidermoid Adenocarcinoma Malignant mixed Adenoid cystic Acinic

Distrbn. of histological types :

% 32 16 14 11 11 16 41 17 12 10 9 9 2 Data from Memorial Sloan-Kettering Cancer

Undifferentiated and squamous Submandibular (n = 383 cases) Adenoid cystic Acinic Malignant mixed Mucoepidermoid Undifferentiated Squamous Adenocarcinoma 7/8/12

adenoma Parotid > Sub mandibular

Benign: Pleomorphic

Painless,slow growing ,Ipsilateral and more in females Has a pseudo capsule; Recurrence after excision common

5-10% chance for malignant Papillary Cystadenoma transformation Lymphomatosum Warthin tumor, confined to parotid(Tail) B/L in 10% ;more in older men; Recurrence rare after surgery

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Malignant conditions: Mucoepidermoid ca:

MC malignancy of SG;90% in parotids f/b Hard palate and minor SGs. Majority are slow growing Most frequent SG tumor in children Behavoiur WD vs PD

Adenocarcinoma: 7/8/12

Malignant Mixed Tumors

From benign conditions like Pas Pathlogically carcinosarcomas Aggressive behaviour with 20% risk of local recc. Propensity of LN mets >25%

Carcinoma Ex Pleomorphic 7/8/12 Adenoma

Adenoid Cystic Carcinoma:

MC type in Submandibular and Minor SGs Solid HP (Undiff)- more malignant behaviour Typical natural history LN mets rare(<5%) PNI+ Pulmonary mets - upto 40% Mostly in parotid 7/8/12

Acinic cell carcinoma:

Age Histolo Inciden Predil. Sex Favore Node gy ce (Decad Predil. d Site Mets e) Acinic cell 4 5th F>M Parotid 10 carcino ma Adenoid cystic 2-5 carcino ma

7th Nerve Inv. 3

Recurr.

Distant Mets

10-22

Rare

5th-6th F = M

Minor 15 salivary

26

High*

28

Mucoepidermoid carcinoma Low 1st-2nd grade 17-20 4th-5th M > F High grade 7/8/12 6th

None

60

8 High*

17 75

33

Age Histolo Inciden Predil. Sex Favore Node gy ce (Decad Predil. d Site Mets e) Maligna nt 4 mixed tumor Squam ous cell 0.1-3 carcino ma Adenoc arcinom2.8 a Undiffe rentiate d 3 carcino ma 7/8/12 Parotid and submaxil33 lary glands Parotids and High* salivary duct Parotid 50

7th Nerve Inv.

Recurr

Distant Mets

7th

M>F

14

30-40

31

None

None

High*

70

High*

5th-6th None

67

19

7th-8th F > M

None

50

23

High*

30

Lymphatic Spread Histologic Subtypes

Anaplastic Epidermoid Adenocarcinoma Mucoepidermoid Malignant mixed Acinic Adenoid cystic Oncocytoma 7/8/12

(%) 86 21 22 14 16 2 2 0 Data from Armstrong etal

Swellings related to SGs

Mucocoele Ranula Necrotising Sialometaplasia

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Clinical Presentation

Painless slow growing mass in most of benign. 1/3rd of parotid ca CN 7 inv. But only 10-20 % present with pain Multiple CN inv in case of PNI tumors Parotid masses mostly in tail. Most malignant salivary gland tumors are seen in patients 5060 years old, 2% in chil-dren <10 years old, and 16% in patients <30 years old. 7/8/12

Facial nerve involvement Indurations / ulceration of skin , mucous membrane Lymph node metastasis Rapid tumor growth
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Indicators of malignancy

DDx of a Parotid mass Metastases to intraparotid nodes/ Lymphoma

Reactive adenopathy Fatty tail of parotid Chronic parotitis Sarcoidosis HIV infection Calculus in duct with obstruction Neoplasms of mandible Cysts (dermoid, bronchial cleft) Prominent transverse process of C1 vertebra 7/8/12 Hemangioma, lipoma, lymphangioma

Natural History is the initial route Local invasion

,depending on location and histologic type. In Parotid ca -fixation to structures in 20%. Skin invasion is more often seen in parotid tumors (10%), compared with submandibular tumors (3%) Approximately 25-35% of patients with a malignant parotid salivary gland tumor present with facial palsy from cranial nerve invasion. Lymph node involvement for parotid 7/8/12

LN mets Parotid-18%,SM-28%, Tumors from oral cavity presents with cervical node metastases of less than 10%. Nasopharyngeal SG tumors have a high risk of occult metastases (50%) The risk of + findings in the neck may be based on a combination of T-stage and histology.The highest risk -for SCC, UDC, and salivary duct cancer Distant Mets lung>bone >liver. 7/8/12

Natural History

Work up

History and clinical examination esp. CN,trismus Basic Investigations-CBC , CXR FNAC CT or *MRI Indications: (1) deep lobe parotid tumors, (2) neurologically symptomatic tumors, (3) recurrent tumors, and (4) large size (5) Minor SG tumors In secondary dep. in SGT -- work up for 7/8/12 the primary.

AJCC STAGING-Major SG Malignancy

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NX N0 N1 N2 a b c N3 Stage 1 Stage 2 Stage 3 Stage 4 A Stage 4 B Stage 4 C 7/8/12

Cannot be assessed No LN mets I/L single <= 3 cm I/L single > 3 - 6 cm M0 No Distant Mets Distant Mets I/L multiple < = 6 cm M1 B/L, C/L <= 6 cm > 6 cm T1 N1 M0 T2 N0 M0 T3 N0 MO T4a N0/ N1 M0 T4b Any N M0 Any T Any N M1 T1-T3 N1 M0 T1-T4a N2 M0 Any T N 3 M0

Staging: Additional Descriptors

Residual Tumor (R) RX: Presence of residual tumor cannot be assessed R0: No residual
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LN status. High grade tumors- 49% LN mets. Size of LN EC Extn from LN Clinical location of Cervical LN ECS -clinical and pathological Larger T size & CN inv.--poor prognosis. Adenoid cystic, ductal, and undifferentiated carcinoma -highest 7/8/12 rates of distant mets.

Prognostic Factors Grade , postsurgical residual disease &

Prognosticati on

Spiro et al. (434 Patients, MSKCC)

90% treated surgically Cause specific 5yr cure rate 44%,10y32%,15y-21% Mortality -51% due to original cancer Adenoid cystic- poorest prog, about 20% surv w/o recurrence Adeno ca- IM outlook, about 35%w/o recurrence ca-Best control rate, about

Mucoepidermoid 7/8/12

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Thank You.