Dr.

Deepak GOyal
Introduction
 Classification
Benign Malignant
 Pleomorphic adenoma
• Mucoepidermoid carcinoma
 Warthin’s tumor
• Adenoid cystic carcinoma
 Oncocytoma
• Carinoma ex- pleomorphic adenoma
 Lymphangioma
• Acinic cell ca
 Haemangioma
• Adenocarcinoma
 canalicular adenoma,
• Salivary ductal carcinoma
 basal cell adenoma
• Squamous cell carcinoma
 myoepithelioma
• Non-hodgkin’s lymphoma
 EPIDEMIOLOGY

 2-3%of all head and neck neoplasms.

 Benign tumors account for 63% to 78% of all salivary gland neoplasms.

 (64%-80%), in the parotid glands ,malignancy (15%- 32%).

 7-11% occur in the submandibular glands, malignancy (37% - 45%).

 less than 1% in the sublingual glands, malignancy (70%-90%),

 9%-23% in the minor glands.

Rule of 80’s:
-80% of salivary gland tumors occur in the parotid

80% of parotid tumors are benign

-80% of parotid tumors are Pleomorphic adenomas

-80% of parotid Pleomorphic adenomas occur in the superficial lobe

-80% of untreated Pleomorphic adenomas remain benign

Etiologic Factors
 Radiation exposure

 Genetic predisposition

 Tobacco

 Chemical carcinogens

 Viruses
PLEOMORPHIC ADENOMA

 Most common of all salivary gland neoplasms

 80-90% of parotid tumors

 Of the minor salivary glands most commonly occurs in the

palate ,upper lip

 4th-6th decades

 M:F = 1:3-4
PLEOMORPHIC ADENOMA

 Slow-growing, painless , firm mass

 Encapsulated

 Mixed tumor: contains both epithelial and mesenchymal elements

 It sends pseudopod-like extensions ‘into surrounding tissue

 Malignant transformation is 10% if observed for more than 15 years.

 Because most of the tumors arise from the superficial lobe, a superficial
parotidectomy is often required.

 Recurrent pleomorphic adenoma is an uncommon but challenging problem.

 There are frequently multiple foci of recurrence that may continue to manifest
over several years.
Warthin’s tumor(papillary cystadenoma lymphomatosum )
 2nd most common after pleomorphic adenoma

 Commonly seen 7th decade

 Male: female (7:1)

 Associated with cigarette smoking

 Almost Exclusively in parotid gland Parotid tail

 10% bilateral
 Usually Fluctuant, slow growing

 Encapsulated cystic lesion

 Histologically: epithelial & lymphoid elements

 Never malignant

 Wide local excision

 parotidectomy with facial nerve preservation

Oncocytoma (oxyphil adenoma)
 Rare 1 % of benign salivary tumor

 6th decade

 No gender predilection

 Parotid ,Submandibular gland

 Minor salivary glands: palate, buccal mucosa,

 Slow growing ,painless

 The treatment of choice for is surgical excision.

Malignant neoplasms
 Shorter duration

 Grow rapidly or history of slow growth with sudden rapid activity

 Fixed to surrounding tissues

 Overlying skin or mucous membrane may be ulcerated or inflamed

 Surface telangiectasia

 Nerve involvement

 Regional lymph nodes may be enlarged

Mucoepidermoid Carcinoma

 2nd most common salivary gland tumor

 Most common salivary gland malignancy

 Parotid 80% - 90% of cases

 Age: 5th – 7th decades

 Gender: slight female predilection

 Site: parotid gland, palate

 Etiology: radiation exposure

 It contain two major elements:

 mucin producing cells & epithelial cells of epidermoid variety & according to that classified into
Low grade
Intermediate
High grade

 Low-grade: slow growing, painless mass

 High-grade: rapidly enlarging, +/- pain

Adenoid cystic carcinoma(Cylindroma)

 2nd most common salivary gland malignancy

 Infiltrates widely into the tissue planes & muscles

 Perineural spread

 Commonly in submandibular gland, sublingual or minor salivary glands

 Slow growing but aggressive neoplasm with a remarkable capacity of recurrence.

 Infrequent cervical metastases

 High degree of late distant metastases

 Treatment
 Complete local excision
 Tendency for perineural invasion: facial nerve sacrifice
 Postoperative RT
 Prognosis
 Local recurrence: 42%
 Indolent course: 5-year survival 75%, 20-year survival 13%
ACINIC CELL CARCINOMA

 6% to 8% of all salivary malignancies

 Mostly in parotid

 3% Shows bilateral involvement

 Has a low-grade behavior

 Associated with the best survival rate of any salivary malignancy

ACINIC CELL CARCINOMA
 They seldom metastasize but they have high tendency to recur locally

 Primary treatment is complete surgical resection with neck dissection limited to the therapeutic
setting.

 Postoperative radiation is not routinely advised

Carcinoma ex-pleomorphic adenoma

 Malignant degeneration can occur in 3% to 7 % of

pleomorphic adenomas.

 Parotid > submandibular > palate

 Risk of malignantdegeneration
 1.5% in first 5 years
 9.5% after 15 years

 Typical history of slowly growing mass demonstrating sudden increase in

the growth.
 Treatment
 Radical excision
 Neck dissection (25% with lymph node involvement at presentation)
 Postoperative XRT
 Polymorphous Low-Grade Adenocarcinoma
 2ND most common malignant intraoral tumor of the salivary glands.
 Palate (60-70%) > buccal mucosa (16%) > upper lip, retromolar area,
base of tongue.
 F:M = 2:1 & common in 5th to 7th decade.
 A painless mass in the palate is the most common presentation.
SALIVARY DUCT CARCINOMA

 High grade aggressive tumor

 from excretory duct cells in major salivary gland mainly
 Microscopic feature remarkably similar to mammary intraductal carcinoma
 35% recurrence
 62% distant metastasis
 Neural invasion and extraglandular extension are commonly seen.
 Most patients die within three years.
SALIVARY DUCT CARCINOMA
ADENOCARCINOMA:

 Ranging from low grade well differentiated to high grade invasive lesions
 Common in major glands
 Originate from excretory or striated ducts
 Cystic or solid, may be papillary or non-papillary in growth pattern
 Prognosis depend on grade
SQUAMOUS CELL CARCINOMA

 Rare to be primary & common to be secondary from intraparotid lymph node or direct
involvement

 Should be differentiated from mucoepidermoid carcinoma by presence of mucin on

electronmicroscope with stain or immunohistochemical test

 Incidence 0.3% -1.5% in major gland 50% nodal metastasis

 M:F = 2:1
 7th-8th decades
 TR: Surgery + Neck dissection + Postop. RT
LYMPHOMA:

 5% of all extranodal lymphoma affect salivary gland

 90% occur in parotid

 85% are N H L

 Its risk in Sjogren’s syndrome is 44 fold higher

SECONDARY TUMORS:

 The majority of metastasis are caused by lymphatic spread from cutaneous

malignancy of the head & neck

 Hematogenous metastasis are rare & majority from lung, kidney & breast

 Contiguous extension of facial sarcomas

 10% of malignant parotid gland tumors

 40% are SCC, & 40% are melanoma

STAGING
STAGING:
Stage I T1N0M0
Stage II T2N0M0
Stage III T3N0M0 or T1-3 N1M0
Stage IVA T4aN0-1M0 or T1-4a N2M0
Stage IVB T4bNxM0 or TxN2-3M0
Stage IVC TxNxM1
Evaluation of patient

History Important points in the history

 Mass (duration, rate of the growth, presence of pain)
 Facial paralysis, B/L
 Cervical lymphadenopathy
 Eyes and joints symptoms
 H/O exposure to radiation
 Ipsilateral weakness or numbness of tongue
Examination:-
 Size of the mass
 Overlying skin, Skin fixation, mobility
 Lymphadenopathies
 Cranial nerves
 Intraoral examination
Investigations

 USG
 X ray chest
 OPG To R/O mandibular involvement.
 CT SCAN
 MRI
USG
 Distinguish intrinsic from extrinsic tumors
 It can be used to differentiate solid from cystic masses in the salivary glands
 USG guided FNAC
CT/MRI
 Anatomical localization
 Local, regional ,distant invasion

MRI IS BETTER ??
 Excellent assessment of margins
 Deep extension and infiltration
 Bone marrow invasion
 Perineural spread
 Intracranial extension
Fine-Needle Aspiration Biopsy

 Accuracy well established

 Sensitivity = 54-95%
 Specificity = 86 - 100%

 Confirms possibility
 Lymphoma/inflammatory masses.

 Allows preoperative assesment of

 Nature of tumour
 Extent of resection (conservative/radical)
 Management of facial nerve (high grade adenoid cystic)
 Likelihood of neck dissection (high grade).
Open biopsy
 Contraindicated
 Justified in minor salivary gland tumor
 Ulcerated lesion
 where fine needle aspiration cytology suggests lymphoma,
 In cases of diffuse salivary enlargement
Frozen section
 may be useful when
 preoperative FNA is non-diagnostic,
 when the FNA diagnosis is at odds with the clinical and/or intraoperative findings
 The results of frozen section may help in intraoperative decision-making. In cases where frozen
section shows high-grade carcinoma, the surgeon may proceed to perform at least a limited neck
dissection with the parotidectomy
MANAGEMENT
 TREATMENT
 Surgery
 Radiotherapy
 Chemotherapy
 Factors that influence treatment
 Age
 Metastatic spread
 Facial nerve involvement
 Mandibular / Temporal bone involvement
 Skin
 Site of tumor
 Size, Extent, Grade & stage
 Surgery
Benign tumors
 Benign salivary gland tumors should be excised completely with an adequate margin to avoid local
recurrences

 Simple enucleation not appropriate treatment recurrence rate 21-45%

 1 cm margin has been shown to be adequate.

 Cutting into the tumour should be absolutely avoided as it can lead to tumor spillage
 Surgery
Benign tumors

 Superficial parotidectomy

 partial superficial parotidectomy,

 Deep lobe tumors -Total parotidectomy with facial nerve preservation.

 Parapharyngeal tumors -cervical-parotid approach and with or without a mandibulotomy.

 Surgery
Benign tumors

 A tumor of the submandibular gland requires submandibular gland resection

 If the tumor originates from a minor salivary gland, the tumor and a cuff of normal
tissue should be excised.
 Surgery
Malignancies

 The mainstay of treatment for salivary carcinomas is surgical resection with or without postoperative
radiotherapy

 The extent of surgery is dependent on the size and site of the tumour

 The goal of surgical treatment is to achieve local control

 As a general rule, every effort should be made to preserve a nerve which was functioning normally
preoperatively
 Surgery

Facial nerve sacrifice should be reserved for cases of

 preoperative paralysis,
 cases of recurrent malignancy
 gross encasement and infiltration of the nerve
 Surgery

Parotid Gland:

 Size and location determine extent of resection

 Most T1/T2 lesions lateral to the nerve are suitable for a superficial parotidectomy with adequate
margin 1.5cm

 Larger and deep lobe tumours usually require a total conservative parotidectomy with preservation of
the facial nerve

 Patients with high grade and extensive disease (i.e. skin involvement or facial palsy) may require
extended radical parotidectomy
Superficial parotidectomy:

Removal of superficial lobe of the parotid

(superficial to facial nerve)
RADICAL PAROTIDECTOMY

 Removal of
 Both lobes of parotid
 Facial nerve
 Mandibular ramus
 Masseter muscle
 Infratemporal fossa dissection
 Subtotal petrosectomy
Complications of parotid surgery

 Facial nerve injury

 HEMATOMA

 Salivary fistulas

 Infection : Flap necrosis is common

 Frey’s syndrome

 Sialocele

 Numbness over the face and ear

Neck dissection
 Neck dissection should be performed in patients with clinical or radiological evidence of nodal disease

 A prophylactic selective neck dissection should be considered for patients with high-stage or high-
grade
Radiotherapy
 Primary treatment for salivary carcinomas is limited to unresectable tumours

 Postoperative radiotherapy is indicated for:

 Tumours greater than 4 cm,
 Presence of positive surgical margins or
 Facial nerve were preserved despite being adherent to the tumour,
 lymph node metastases
 High grade tumor
 perineural invasion.
 Recurrent pleomorphic adenoma
 Spillage after surgery for pleomorphic adenoma
Radiotherapy
 Preoperative radiotherapy

Given in large tumours to reduce the size and make it better operable, i.e. to down stage the disease
 Prognosis
 Advanced stage, higher histologic grade poor prognosis

 submandibular location poorer outcome

 10 yr survival rates for stage I 82%

II 64% III
50% IV
33%

 Regional lymph node metastases poorer prognosis

Prognosis

 Distant metastases poor prognosis

 Parapharyngeal space extension poor prognosis

 Parotid malignancies better prognosis

 Facial nerve paralysis poor prognosis