THE SUBMANDIBULAR GLAND

Contouring Accuracy Program

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 Outline
1. Refresher Course on the Submandibular Gland
A. What are the submandibular glands?
B. The functions of the submandibular glands
C. “Did you know?”
2. Locating the Submandibular Glands in Medical
Images
A. Limits and borders
B. Relationship to other anatomy
C. Contouring on axial images
D. Window and level considerations
3. Special Considerations for Radiation Therapy
A. Radiosensitivity
B. Notable Protocols & Publications

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 1A. What are the Submandibular Glands?

The submandibular glands are

paired salivary glands.
The submandibular glands are
located bilaterally below the floor
of the mouth, just under the jaw
and towards the back of the
mouth.
They are the second largest of the
salivary glands (the largest being
the parotid glands).

http://rsnaeducation.blogspot.com/2011/09/cervical-lns.html

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 1B. The Functions of the Submandibular Glands

The primary function of the submandibular glands is to control

the release of saliva into the area of the mouth that is just
under the tongue.
Each gland weighs ~15 grams. Together, the two glands
contribute up anywhere from 60-75% of unstimulated saliva
secretion. On stimulation, their relative contribution %
decreases as the parotid glands’ secretion rises up to 50%.
https://en.wikipedia.org/wiki/Submandibular_gland
https://en.wikipedia.org/wiki/Saliva#Daily_salivary_output
Secretions are delivered through submandibular duct, or
Wharton’s duct.
https://en.wikipedia.org/wiki/Submandibular_duct

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 1C. “Did You Know…?”

Afunfew
Summary fun facts
fact statement about
here… saliva…
 Humans produce 0.75 to 2.0 liters of saliva per day. The
submandibular glands are the workhorse of this saliva
production in terms of volume.

 Our saliva is rich with a painkiller six times more powerful than
morphine, called opiorphin.

 Scientific studies suggest that a person’s age can be estimated

within five years by analyzing the saliva (i.e. by measuring the
degree of methylation in DNA).

Here is a neat link with more fun-facts about saliva.

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 2A. Limits and Borders

Superior - medial surface of

the mandible.
Inferior - soft tissue of the
neck, often down to the level
of the hyoid bone.
Medial/anterior - floor of the
mouth.
Posterior - submandibular LN
and carotid sheath

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 2B. Relationship to Muscles

Ramus of
mandible

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 2B. Relationship to Other Anatomy

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 2B. Relationship to Other Anatomy

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 2B. Relationship to Hyoid Bone

GLAND

HYOID BONE

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 2C. Contouring Step-by-Step Guide

1. Locate the ramus of the mandible and identify the

medial pterygoid on its medial surface.
2. Scrolling inferiorly, the superior aspect of the
submandibular gland should become apparent
either medial or inferior to the inferior aspect of
the medial pterygoid/mandible.
3. Contour gland inferiorly as it continues in the soft
tissue of the neck, ending approximately at the
level of the hyoid.

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 2D. Window and Level Considerations

MUSCLE

GLAND

FAT

Low Contrast, i.e. Wide Window High Contrast, i.e. Narrow Window
W = 3000, L = 500 W = 240, L = 20

 Gland tissue = less radio-dense than muscle

 Gland tissue = more radio-dense than fat
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 3A. Radiosensitivity
Structure Name Metric Goal Note

Submandibular Gland Mean Dose ≤ 39 Gy Suggested dose limit;

should not compromise
tumor coverage

Link to RTOG 0912

Comments

It is not entirely clear whether the parotid and submandibular glands share similar dose-
volume responses. Murdoch-Kinch et al. showed that there was recovery of stimulated and
unstimulated salivary flow up to a threshold of 39 Gy.

Submandibular gland sparing is an area of debate. Limited retrospective evidence suggests

that it can be safely done in appropriately selected patients (Gensheimer et al.)

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 3B. Notable Protocols & Publications
RTOG 0912: A Randomized Phase II Study of Concurrent Intensity
Modulated Radiation Therapy (IMRT), Paclitaxel and Pazopanib (NSC
737754)/Placebo, for The Treatment of Anaplastic Thyroid Cancer
Grundmann O, Mitchell GC, Limesand KH. Sensitivity of Salivary Glands to
Radiation: from Animal Models to Therapies. Journal of Dental Research,
2009; 88(10):894-903.
Terhaard CH,et al. The role of radiotherapy in the treatment of malignant
salivary gland tumors. Int J Radiat Oncol Biol Phys, 2005 Jan 1;61(1):103-11
Murdoch-Kinch C-A, Kim HM, Vineberg KA, Ship JA, Eisbruch A. Dose-
Effect Relationships for the Submandibular Salivary Glands and
Implications for Their Sparing by Intensity Modulated Radiotherapy. Int J
Radiat Oncol Biol Phys, 2008; 72(2):373-382.
DOI:10.1016/j.ijrobp.2007.12.033.
Gensheimer et al. Submandibular gland-sparing radiation therapy for
locally advanced oropharyngeal squamous cell carcinoma: patterns of
failure and xerostomia outcomes. Radiation Oncology, 2014; 9:255.
DOI:10.1186/s13014-014-0255-x

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