Salivary gland tumors

Tumors of the salivary glands are uncommon and represent 2-4% of head and neck neoplasms. They may be broadly categorized into benign neoplasms, tumor-like conditions, and malignant neoplasms. The glands are divided into major and minor salivary gland categories. The major salivary glands are the parotid, the submandibular, and the sublingual glands. The minor glands are dispersed throughout the upper aerodigestive submucosa (i.e., palate, lip, pharynx, nasopharynx, larynx, parapharyngeal space). Most (70%) salivary gland tumors (SGTs) originate in the parotid gland. The remaining tumors arise in the submandibular gland (8%) and minor salivary glands (22%). Although 75% of parotid gland tumors are benign, slightly more than 50% of tumors of the submandibular gland and 80% of minor SGTs are found to be malignant. Pleomorphic adenomas (benign mixed tumors) are the most common benign SGTs, comprising 85% of all salivary gland neoplasms. The ubiquitous deposition of the minor salivary glands complicates the diagnosis and management of SGTs. The approach for a suspected tumor of the minor salivary glands begins with a thorough history and a physical examination. Radiographic imaging (CT with or without MRI) and a histopathologic diagnosis (obtained based on fine needle aspiration biopsy [FNAB]) often provide useful information prior to definitive surgical therapy.

1. Adenomas
1 Pleomorphic adenoma 2 Myoepithelioma (myoepithelial adenoma) 3 Basal cell adenoma 4 Warthin’s tumor (adenolymphoma) 5 Oncocytoma (Oncocytic adenoma) 6 Canalicular adenoma 7 Sebaceous adenoma 8 Ductal Papilloma • Inverted ductal papilloma • Intraductal papilloma • Sialadenoma papilliferum

2 . Miscellaneous 1 Nonepithelial tumors 2 Malignant lymphomas 3 Secondary tumors 4 Unclassified tumors 5 Tumor-like lesions • Siladenosis • Oncocytosis • Necrotizing sialometaplasia (salivary gland infarction) • Benign lymphoepithelial lesion • Salivary gland cysts • Chronic sclerosing sialedenitis of submandibular gland (Kuttner tumor) • Cystic lymphoid hyperplasia in patients with acquired immunodeficiency syndrome INCIDENCE Salivary gland tumors …3-4% of all head & neck neoplasm. > 70%of them are Benign.9 Cystadenoma • Papillary cystadenoma • Mucinous cystadenoma 2. Carcinomas 1 Acinic cell carcinoma 2 Mucoepidermoid carcinoma 3 Adenoid cystic carcinoma 4 Polymorphous low-grade adenocarcinoma 5 Epithelial-myoepithelial carcinoma 6 Basal cell adenocarcinoma 7 Sebaceous carcinoma 8 Papillary cystadenocarcinoma 9 Mucinous adenocarcinoma 10 Oncocytic carcinoma 11 Salivary duct carcinoma 12 Adenocarcinoma 13 Malignant myoepithelioma 14 Squamous cell carcinoma 15 Small cell carcinoma 16 Undifferentiated carcinoma 3. 70% originate in parotid gland.

3 .70% of them …plemorphic adenoma. 10% of parotid tumors… mucoepidermoid carcinoma.

4 .

Multi-cellular theory • Salivary gland arise from the adult differentiated counter part of salivary gland unit: Acinar cell : acinous tumor. Excretory duct cells: mucoepidermoid carcinoma & squamous cell carcinoma. Intercalated duct cell: mixed tumor. Striated duct cell: oncocytic tumor.Pathophysiology I. 5 .

• Mostly parotid • Commonly mucoepidermoid carcinoma. Excretory duct stem cell: squamous cell carcinoma & mucoepidermoid carcinoma. 6 . • II. Intercalated duct stem cell: acinous cell carcinoma. Bicellular Theory The basal cell of excretory & intercalated duct act as stem cells. Radiation Several studies have implicate radiation associated neoplasm. mixed tumor & oncocytic tumors. adenoid cystic carcinoma. • no evidence of a causal role of EBV in other primary tumors of the salivary gland. • Does-response pattern.II. Epstein-Barr Virus: • The consistent association of E B V with lymphoepithelial carcinoma of the salivary gland suggest the virus probably plays causal role • Similar pathogenesis of nasopharyngeal carcinoma. • Aetiology I.

• Pain • Fixation • Cervical adenopathy History of malignant skin lesion should be clarified as case of metastatic disease to the parotid. Genetic Factors: Many genetic alternation may be responsible for increased likelihood of developing salivary gland neoplasm as allelic loss. Using Kerosene as cooking fuel. hemorrhage inside the mass. cystic degeneration. monosomy& polysomy. Other factors: • • • Silica dust or wood dust. or malignant transformation) • malignant indicators as:Facial nerve paresis or paralysis.III. Need full examination especially. • The mass itself. Diagnosis I. Weakness or numbness of the tongue or in distribution of branches of trigeminal nerve. Clinical features: Usually present as slowly growing painless swelling A sudden increase in size ( infection. IV. • Cervical lymph node. • • 7 . Warthin’s tumor is strongly associated with cigarette smoking. structural rearrangement. • Oropharynx. • Skin of face or scalp. • C N S.

prolongs course until definitive 8 . requires • multiple biopsies. Fine needle aspiration biopsy: Efficacy is well established • Accuracy = 84-97% • Sensitivity = 54-95% • Specificity = 86=100% Safe. well tolerated Opponents: • Doesn’t change management • Surgery regardless of reported diagnosis • Obscuring final pathologic diagnosis • Frequency of “inadequate” sampling.II.

C T & M R I give better understanding: o Location & extent of the tumor. Color doppler sonography. . Benign tumors Pleomorphic Adenoma − − − − Most common of all salivary gland neoplasms 70% of parotid tumors 4th-6th decades. o Its relation to major neurovascular structure o Perineural spread. -The proper approach to parotid neoplasm is parotidectomy which diagnostic & curative. • • • • • • Conventional radiography & sialography are rarely used.Open biopsy done rarely & in the patient who not surgical candidate & for whom FNAB is not diagnostic. Other imaging studies: Ultrasonography.• treatment. malignant nature of neoplasm • Preoperative patient counseling • Surgical planning • Differentiate between neoplastic and non-neoplastic processes • Avoid surgery in large number of patients III. o Skull base invasion. Radiology: • • IV. F:M = 3-4:1. increases cost Proponent: • Important to distinguish benign vs. Biopsies: -Incisional intraoral biopsy of parapharyngeal tumor should not be performed. o Intracranial extension. o But most of the time can’t be differentiate between benign & malignant entities. 9 . Nuclear imaging using Technetium 99m pertechnetate is rarely obtained because FNAB may provide better information.

Parotid is the most frequent site. shaggy epithelium − Solid areas with white nodules representing lymphoid follicles Histology Papillary projections into cystic spaces surrounded by lymphoid stroma − Oncocytoma − − − − − < 1%of salivary gand tumors. painless. 6th decade. painless mass Gross pathology − Encapsulated − Smooth/lobulated surface − Cystic spaces of variable size. painless mass.− Slow-growing. − Rarely progresive. myopeithelial and stromal components − No true capsule − Tumor pseudopods Warthin’s Tumor papillary cystadenoma lymphomatosum − 6-10% of parotid neoplasms − Older. Gross 10 . Gross pathology − Smooth − Well-demarcated − Solid − Cystic changes − Myxoid stroma Histology − Mixture of epithelial. Slow-growing . Caucasian.firm mass. with viscous fluid. males − 10% bilateral or multicentric − 3% with associated neoplasms − Presentation: slow-growing. M:F = 1:1.

Membranous Hemangioma − − − − − − Benign of endothelial origon. Histological types: Solid .painless. M:F = approximately 1:1. eosinophilic cytoplasm − Central. smooth Orange/rust color Histology − Cords of uniform cells and thin fibrous stroma − Large polyhedral cells − Distinct cell membrane − Granular. Present at birth. Trabecular . • Canalicular Adenoma. round. Tubular . Caucasian > African American. 11 . • Myoepithelioma. − Only one morphologic cell type. Unilateral. vesicular Nucleus Monomorphic Adenomas − < 5% of salivary gland tumors. F > M. Encapsulated Homogeneous. Most common in parotid. 6th decade. • Clear cell adenoma. < 5% of salivary gland tumors. • glycogen-rich adenoma. • Sebaceous adenoma Basal Cell Adenoma − − − − − − − Basal cell is the most common 1.8% of benign epithelial salivary gland neoplasms. > 90% of parotid tumors in children < 1year.rapid-growth . − Subclassified into: • Basal Cell Adenoma.

− It contain two major elements: mucin producing cells & epithelial cells of epidermoid variety & according to that classified into low-grade.− − CT & MRI are dignostic. Malignant Mucoepidermoid Carcinoma Most common salivary gland malignancy. Histology— High-grade − Epidermoid > mucus − Solid tumor cell proliferation − Mistaken for SCCA-Mucin staining − high chance of locoregional recurrence. − − − − − − − Adenoid Cystic Carcinoma − Overall 2nd most common malignancy 12 . painless mass High-grade: rapidly if needed. +/. high grade & intermediate.distant metastasis & shorter survival rate compaired with low grade tumors. Caucasian > African American. − Presentation Low-grade: slow growing.90% of cases. F>M. 3rd-8th decades. Parotid 80% . Spontanouus regression . 5-9% of salivary neoplasms. peak in 5th decade.pain Gross pathology -Well-circumscribed to partially encapsulated to unencapsulated -Solid tumor with cystic spaces Histology—Low-grade − Mucus cell > epidermoid cells − Prominent cysts − Mature cellular elements Histology—Intermediategrade − Mucus = epidermoid − Fewer and smaller cysts − Increasing pleomorphism and mitotic figures. Most common salivary gland tumor in children.

− Distant metastasis continue to occur for as long as 20 years or more & common in lung (90%). papillary cystic& follicular. − 2/3 Occur in female. − Main age is 40-50 years. − It is generally regarded as relatively low grade malignancy & has more favorable prognosis. sublingual and minor salivary glands − M=F − 5th decade − Presentation Asymptomatic enlarging mass Pain. facial weakness/paralysis − Subclassified histologically in:Cribriform. − Lymphatic spread uncommon 15%. 13 . − Acinic Cell Carcinoma − 3% of all salivary gland neoplasm. paresthesias. But the type of pattern do not correlate with biologic behavior or prognosis.Most common in submandibular. solid − Perineural involvement is characteristic of adenoid cystic carcinoma & occur in 20-80%. − They seldom metastasize but they have high tendency to recur locally. − 80-90% in parotid. Carcinoma ex-pleomorphic adenoma (most common variety). Malignant mixed tumor − − − − − Epithelial & mesenchymal elements. − 15% of all parotid tumors. − 3% Shows bilateral involvement. − Four histological patterns identified solid. − Second most common salivary gland in children. tubular. − Well circumscribed tumor with fibrosis tissue macroscopically. microcystic. Incidence increase by duration & recurrence of pleomorphic adenoma. 3-12% of salivary gland tumor. ¾ in parotid.

tubular & cribriform subtypes. 40% of patient died by their disease. Ductal cell population. Common in female 2:1 Lymph node metastasis 9% Local recurrence 17% No distant metastasis. Slow growth. − Microscopic feature remarkably similar to mammary intraductal carcinoma. Sold. calcification or excessive hyalinization. Cystic or solid. invasive & non-invasive: − Degree of the invasion determine the prognosis which <8-mm 5-year survival rate is 100%. High incidence of local recurrence 50% especially with sold type. hemorrhage. Originate from excretory or striated ducts. Mostly involve the parotid at age 50-80 female. − 35% recurrence. − Polymorphous low grade adenocarcinoma − − − − − − − − Known also as terminal duct or lobular carcinoma.Microscopic foci of necrosis. − 62% distant metastasis − 77% died of the disease. Adenocarcinoma − − − − − Ranging from low grade well differentiated to high grade invasive lesions. Prognosis depend on grade. 14 . Majority in oral cavity (palate or buccal mucosa). may be papillary or non-papillary in growth pattern. Common in major gland. Salivary duct carcinoma High grade aggressive tumor from excretory duct cells in major salivary gland mainly. − − − − − Epithelial-Myoepithelial carcinoma − − 1% of salivary gland neoplasm. − Invasive type show 25% regional & 33% distant metastasis. Distant metastasis show <50%. − 2 Subgroups.but > 8.

− 50% nodal metastasis.5% in major gland. Linked to E B virus. − Undifferentiated Carcinoma − − − − − − Lack of histological characteristics. 5% of all extranodal lymphoma affected salivary gland. occur in 1st year. kidney & breast − Contiguous extension of facial sarcomas. 40% are SCC. Management Staging 15 . Nodal or extranodal in the salivary gland. High in china Indistinguishable histological from undifferentiated carcinoma of nasopharynx. Lymphoma − − − − − Secondary tumors The majority of metastasis are caused by − lymphatic spread from cutanous malignancy of the head & neck. 85% are N H L.XRT.Squamous cell carcinoma Rare to be primary & common to be secondary from intraparotid lymph node or direct involvement. − 7th-8th decades − TR:surgery + Neck dissection + Postop. 2/3 of SCCs. Melanoma correlate with thickness of primary tumor.3% -1. & 40% are melanoma. 10% of malignant parotid gland tumors(2ry). Primary or disseminated. − Should be differentiated from mucoepidermoid carcinoma by presence of mucin on electron microscope with stain or immunohistochemical test. Its risk in Sjogren’s syndrome is 44 fold higher & has bad prognosis. − Incidence 0. − M:F = 2:1. 90% occur in parotid. − Hematogenous metastasis are rare & majority from lung.

Preoperative weakness or paralysis Intraoperative evidence of gross or microscopic infiltration. − Large tumor and tumor involving the deep lobe usually require total parotidectomy. − The sacrificing more likely with large & high grade tumor or that one extend from superficial to deep lobe. I. − Surgical margin on distal & proximal nerve stumps should be checked due to the possibility of perineural spread. − 16 . − The facial nerve is dissected & preserved unless it is directly involved by the tumor. localized tumor of the superficial lobe may be adequately treated with superficial parotidectomy. Surgery: Small.Treatment for salivary gland cancer The principal treatment of salivary gland tumors is surgical resection with save margins used either as single modality or conjunction with adjuvant radiotherapy.

P. − III. Chemotherapy 17 .Radiotherapy Adjuvant radiotherapy is superior to surgery alone & effective in improve locoregional control & highly recommended in patient with poor prognosis. pressure dressing. − But there is controversy about management of clinically negative neck. − If the symptoms are bothersome we can use antiperspirant. 3) Salivary fistula − Uncommon & self limited. − Incidence 35-60%. − Diagnosis depend largely on the patient’s symptoms but can be confirm by Minor’s starch & iodine test. so the elective neck dissection or selective (supraomohyoid) neck dissection should be considered. − IV. glycopyrrolate lotion. the patient need comprehensive cervical lymphadenectomy. − Due to cross re-innervation between the postganglionic secretomotor parasympathetic fibers to the parotid gland & the postganglionic sympathetic fibers supplying the sweat glands of the skin. The incidence of occult regional disease is relatively high. II. − In high-grade or large tumor. − In inoperable tumor the neutron irradiation alone is the therapy of choice & superior to conventional proton or electron therapy & even superior to debulking surgical procedure. − Complication of Parotidectomy 1) Frey’s syndrome (Gustatory sweating): − Symptoms vary in severity. Neck Dissection: If there is metastatic cervical L.A. − In low-grade malignancy the elective neck dissection not recommended. repeated aspiration of fluid collections or oral anticholinergics. tympanic neurectomy or muscle flap or sheet of facia between the skin and the parotid ped. − Treated by wound care.Tumors extending beyond the parotid gland may require resection of surrounding structures up to subtotal petrosectomy. 2) Facial nerve paresis or paralysis. − Clear sialorrhea or fluid collections.

− Adenoid cystic carcinoma considered a high grade malignancy although histologic pattern have different biologic behavior. The effect of perineural spread in the prognosis of adenoid cystic carcinoma still controversial. Perineural spread: In squamous cell carcinoma the perineural spread show poor prognosis.Bone involvement. undifferentiated carcinoma & salivary duct carcinoma are considered high-grade tumors while acinic cell carcinoma & polymorphous low grade adenocarcinoma are considered low-grade tumor.Present at more advance stage. VII. − Adenoid cyst carcinoma 10&20 years survival rate drop from 62 & 50% to 38 & 8% with nodal metastasis. Site: The prognosis & also the local recurrence after treatment have a definite correlations with primary site of origin which better in major salivary glands than minor salivary glands mainly due to: . Squamous cell carcinoma. V. malignant mixed tumors. Surgical margins: − − − − Some consider it as the most important factor. . Prognosis I. VI. Nodal metastasis: − Considered as predictor of poor prognosis. − Mucoepidermoid carcinoma highly correlated with tumor grade. these response have not resulted in significant improvement in long survival rate. IV.High incidence of extension & fixation. The incidence of local recurrence & regional metastasis are lowest in patient with stageI.Stage: The most important factor. II-Histology & Grade: The biologic behavior depend largely on the histologic type of malignancy. . − − III.Although the salivary gland malignancy show some response to various chemotherapeutic agents. Facial Nerve paralysis: 18 . Microscopic positive margin need radiotherapy to achieve good prognosis. But any how the perineural spread in major nerve indicate adverse prognostic factor.

Pain: − − Patients with pain appear to have a less favorable outcome. Gender: Men have poorer outcome. Most frequently in adenoid cystic carcinoma & undifferentiated carcinoma. Distant metastasis: − − X.Although facial nerve paralysis may not be associated with 100% mortality rate. − 19 . it is an indicator of poor prognosis. 20% of parotid malignancy. Its presence increase likelihood of local invasion of bone or sensory nerves. Lung. bone & brain. VIII. IX.

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