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Salivary Gland Neoplasm

Dr. Saad Al-Muhayawi. M.D., FRCSC


Associate Professor & Consultant
ORL Head & Neck Surgery
Salivary gland neoplasm
1. Major salivary gland
a. Parotid gland
b. Submandibular gland
c. Sublingual gland

2. Minor salivary gland


600 – 1,000 minor salivary gland distributed throughout
the mucosa of the upper aerodigestive tract (more
common in the soft and hard palate).
80% of salivary gland tumor occur in the parotid.
10 – 15% in the minor salivary gland.
5 – 10% in the submandibular gland.

80% of the parotid tumor are benign.


The most common is pleomorphic adenoma.
50% of the submandibular gland tumor are benign.
30% of the minor salivary gland are benign.
Malignant disease of the parotid
Pathogenesis:
1. Reserve cell theory
(currently the favored
theory) of salivary gland
neoplasia states that salivary
neoplasms arise from
reserved (stem cells) of the
salivary duct system e.g.
adenonoid cystic carcinoma
and acinic cell carcinoma
arising from intercalated
duct reserve cell. The
mucoepidermoid carcinoma,
squamous cell carcinoma,
and salivary duct carcinoma
arise from excretory reserve Salivary gland unit
cell.
2. Multicellular theory of
salivary gland neoplasia
states that salivary
neoplasm arise from
already differentiated
cells along the salivary
gland unit. For example,
squamous cell carcinoma
arises from the excretory
duct epithelium and
acinic cell carcinoma
arise from the acinar
cells.
Salivary gland unit
What are the most common benign
tumor of the parotid?
1. Pleomorphic adenoma (benign mixed tumor).
2. Warthin’s tumor (papillary cyst adenoma
lypmhomatosum).
3. Monomorphic adenoma
a. Basal cell adenoma
b. Canalicular adenomas
c. Oncocytoma
d. Myoepitheliomas
4. Granular cell tumor
5. Hemangioma
What are the most common malignant neoplasm of
the parotid gland?
1. Mucoepidermoid carcinoma – 40%
It can high, intermediate, and low-grade base on the
clinical behavior and the tumor differentiation which is
related to the percentage of mucinous to epidermoid cell.
2. Adenoid cystic carcinoma – 10%
Adenoid cystic carcinoma are unique among the salivary
gland tumors because of their indolent and protracted
clinical course.
Characterized by preneural spread including skip lesions.
The disease thus specific survival continuous to declined
for more than 20 years after initial treatment.
3. Acinic cell carcinoma – 10 – 15 % of
It is considered a low-grade tumor.
4. Malignant mixed tumor - 7%
It is considered a high-grade malignancy.
5. Polymorphous low grade adenocarcinoma – 10%
It is a low-grade variant of adenocarcinoma.
6. Adeno carcinoma – 10%
It is a high-grade with poor prognosis.

7. Squamous cell carcinoma – 4%


It is high-grade, more common in elderly patients, and
can confused with high-grade mucoepidermoid
carcinoma.
The malignant parotid tumor can be classified into:

1. High-grade: aggressive behavior, local invasion, and


lymph node metastasis.
- high grade mucoepidermoid carcinoma
- adenoid cystic carcinoma
- carcinoma ex phelomorphic adenoma
- adenocarcinoma
- aquamous cell carcinoma
- undifferentiated carcinoma
2. Low-grade malignancy
- low grade mucoepidermoid carcinoma
- pholymorphous low grade adenocarcinoma
- acinic cell carcinoma
- low grade adenocarcinoma
- basal cell carcinoma
3. Intermediate grade
- intermediate grade mucoepidermoid carcinoma
- intermediate grade adenocarcinoma
- oncocytic carcinoma
Evaluation of patients with a parotid mass

1. History
Important points in the history:
- Parotid mass (duration, rate of the growth,
presence of pain)
- Facial paralysis
- Cervical lymphadenopathies
- Eyes and joints symptoms
- History of exposure to radiation
2. Examination
- Size of the mass
- Skin fixation
- Cervical adenopathies
- Facial nerve functions
3. Investigation
C.T. and MRI are both effective modalities for
imaging the size, the local, and the regional
extension of the primary tumor and the neck
metastasis.
C.T. saliography – it replaced now by high-
resolution contrasted C.T. and MRI.
4. FNAB
- The accuracy is around 90% depend on the
techniques of aspirate and the
cytopathologist.

5. Superficial parotidectomy is considered as a


diagnostic and therapeutic for most benign
tumors.
The post-operative complications:
1. Skin flap necrosis
2. Hematoma
3. Salivary fistula and sialoseles – it presents as an
opening in the suture line below the lobule of the
ear.
4. Facial nerve paralysis – which could be:
a. Temporarily: 5 – 10% of the patients.
b. Permanent: less than 2% of the cases.
5. Numbness of the ear due to injury of great auricular
nerve.
6. Xerostomia not common in the superficial
parotidectomy (30% of salivary producing tissue).

5. Frey’s syndrome (Gustatory sweating syndrome)


Incidence in 50% of the patients.
Etiology: post-operative growth of the interrupted
preganglionic parasympathetic nerve branches to
the parotid into the more superficial sweat glands.
The diagnosis is usually made from the history but
can be confirmed by the starch-iodine test.
What is starch-iodine test?
Paint the affected skin with iodine, dust the
skin with the starch, feed the patient. The
appearance of bluish discoloration of the
overlying skin due to reaction of starch
and iodine in the presence of moisture
(sweat.
How do you treat Frey’s syndrome?
Although frey’s syndrome is usually a minor problem, it
may require treatment which include:
1. Parasymphatholytic creams such as glycopyrrolate
lotion may also be applied to the skin or scopolamine
cream 3%.
2. Apply anti-perspirant to avoid sweating.
3. Jacobsen’s neurectomy via tympanotomy approach.
4. Elevating skin flap and placing tissue such as fascia,
dermis, or creating SCM muscle flap and if there is a
big defect you can use regional flap as a PMMF.
Facial nerve paralysis
In parotid malignancy
a. Patient with clinically pre-op facial
nerve paralysis. What to do?
Intra-operative resection of the involved
part of the facial nerve and primary
grafting using greater auricular nerve or
sural nerve.
Post-operative radiotherapy (high-grade)
b. Patient with a normal facial function
but intra-operative involvement of the
facial nerve. What to do?

Careful dissection of the tumor of the


facial nerve without sacrifying the facial
nerve and followed-up with radiotherapy
treatment.
During an operation on the
parotid, where do you find
the facial nerve?
1. Tragal cartilage
(pointer) – always
point to the facial
nerve.
The facial nerve is
1 cm. inferior and
1 cm. medial to
the pointer.
2. Tympanomastoid
fissure – FN is 4
mm inferior to
the tympano
mastoid fissure as
it exit from the
stylo mastoid
foramen.
3. Posterior belly of
digastric muscle. The
facial nerve is superior
to the upper border of
the belly of the digastric
muscle.
4. Retrograde inferior
approach to the
facial nerve.
The lower branch of
the facial nerve
invariably can be
found immediately
external to the
posterior facial
vein as it exits the
lower pole of the
parotid gland.
5. Retrograde anterior
approach.
The parotid duct is
constant imposition
as it goes Parotid
duct
horizontally across
the border of
masseter muscle.
It’s always
accompanied by a
branch of buccal or Angle of
mandible
zygomatic branch
within 1 cm. of the
duct.
Does the grading make
difference in management
of the parotid
malignancy?
Stage T N M NX Regional lymph nodes cannot be assessed
I T1 N0 M0 N0 No cervical nodes metastasis
II T2 N0 M0 N1 Single ipsilateral lymph node  3 cm
III T3 N0 M0 N2a Single ipsilateral lymph node  3 cm and
T1-3 N1 M0  6 cm
IVA T1-3 N2 M0 N2b Multiple ipsilateral lymph node
T4a N0-2 M0 metastases, each  6 cm
IVB T4b Any N M0 N2c Bilateral or contralateral lymph node
metastases, each  6 cm
Any T N3 M0
N3 Single or multiple lymph node metastases
IVC Any T Any N M1  6 cm
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor MX Distant metastases cannot be assessed
T1 Tumor  2 cm, no extraparenchymal extension M0 No distant metastases
T2 Tumor  2 cm,  4 cm, no extraparenchymal M1 Distant metastases present
extension
T3 Tumor  4 cm or extraparenchymal extension Modified, with permission, from Greene FL,
(or both) Page DL, Fleming ID et al
(eds.):American Joint Committee on
T4a Tumor invades skin, mandible, ear canal,
Cancer: AJCC Cancer Staging Manual, 6th
facial nerve, or any of these structures
ed. New York, Berlin, Heidelberg:
T4b Tumor invades skull base or pterygoid plates, Springer-Verlag, 2002.
or encases carotid artery
Group 1: T1 and T2NO low-grade malignancy

Treatment is excision of the tumor with cuff of a


normal tissue.
Facial nerve is preserved.
Regional lymph node evaluated at the time of
surgery.
No post-op radio therapy unless the resection
margin is not clear.
Group 2: T1 and T2NO high-grade malignancy

Treatment is total parotidectomy with excision of the first


echolon node (digastric and submandibular nodes).
Facial nerve involvement:
a. patient with facial paralysis pre-operatively.
Resection of the facial nerve with primary grafting.
b. patient with normal facial function pre-op.
Resect the tumor of the facial and post-operative
wide field radiation.
Group 3: T3NO or any N+ high-grade or
recurrent cancer.

Treatment is total parotidectomy


Modified radical neck dissection
Post-operative wide field radiotherapy
Facial nerve as in group 2
Group 4: include all T4 tumor
Treatment is radical parotidectomy with modified
radical neck dissection and resection of masseter
muscle, part of the mandible or mastoid or ear
canal as required.

Resection of the facial nerve with the tumor and


primary grafting.

Followed by wide field post-operative radiotheray.


Points to remember in parotid surgery:
1. Pre-op evaluation: general condition of the patient,
hemoglobin, LFT and U & E’s

2. Consenting patients for possible facial weakness.

3. Operating in bloodless field by:


a. hypotensive technique
b. elevation of the head of the bed
c. delicate tissue handling
d. proper hemostasis
4. Using facial nerve monitoring during
operation and at the end of operation.

5. Exposure of the eye and the operative side of


the face.

6. Modified blair incision.

7. Landmark for the facial nerve.


Indications of neck dissection
1. Neck dissection is a recommended treatment of the
neck for the malignant salivary gland tumor,
when?

2. If there is a clinically cervical adenopathies (15%).


Parotid tumor bigger than 4cm, why?
(the risk of occult metastasis over 20%).

3. High grade malignancy, why?


(the risk of occult metastasis over 25%).
Indications of post-operative
radiotherapy
1. High-grade tumor
2. Gross or microscopic residual disease
3. Tumor involving or close to the facial nerve
4. Recurrent disease
5. Documented lymph node metastasis
6. Extraparotid extension
7. Deep lobe cancers
8. All T3 and T4 cancers