Literature Reading

SALIVARY GLANDS TUMOR

Presented by : Tita Puspitasari

Supervisor :

dr. Nur akbar Aroeman, dr., Sp.THT-KL (K), FICS

Department of Otorhinolaryngology-Head & Neck Surgery

Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital
Bandung
2020
INTRODUCTION

Salivary glands:
• Major: Paired structures, parotid, submandibular, and sublingual

• Minor: Submucosal throughout the upper aerodigestive, nasal cavity-

lips-esophagus and trachea

• The salivary gland network is composed of secretory elements that

produce saliva upon stimulation (smell, taste, and thought)

• Saliva: Lubrication and protection of mucous membrane, dentition,

and provides clearance of foreign materials.

PATHOLOGY Salivary glands:
Secretory acinus
Ducts
Myoepithelial cells

Acini:
Serous : zymogen granules,
principle secretion is
amylase
Mucous: cytoplasm of
mucinous cells
is clear and contains mucin
Mixed serous and mucinous

Secretions from the acini

empty into smaller duct to
branching larger duct
into the main excretory duct
EPIDEMIOLOGY & PREDISPOSING
FACTORS
• Rare.
• 3% to 6% of all tumors of the head and neck region.
• Incidence 2.5 to 3.0 cases/100,000/year in the United States.

• Predisposing factors: History of exposure radiation, wood dust

(especially soft wood) and chemicals used in the leather tanning
industry
 DIAGNOSIS

Maligna:
• Enlarged ipsilateral cervical lymph
• Asymptomatic mass.
• Facial nerve dysfunction
• Majority arise in the
• Invasion of the overlying skin
superficial lobe.
• Rubbery nodular mass.
• anterior to the lobule of
the ear in the region of • Pain signifies an obstructive and/or
the tail of the parotid inflammatory phenomenon and may prove to
gland. be sialadenitis.
 DIAGNOSIS

Deep lobe of the parotid

Tumors may arise in Diffuse enlargement of
gland:
accessory parotid tissue the entire parotid gland:
• Diffuse enlargement and
along the course of the
fullness in the
Stensen duct: • Lymphoma, Sjogren’s
retromandibular,
syndrome, and those
extending into the
• Mass in the soft with extensive
parapharyngeal space,
tissues of the eosinophilic infiltrate,
medial displacement of
midportion of the as seen in patients
the soft palate, tonsil,
cheek. with Kim-Kimura’s
and/or lateral pharyngeal
disease
wall.
 DIAGNOSIS

Mixed tumor of the Malignant mixed

submandibular tumor of the
salivary gland. hard palate

Adenoid cystic
Adenocarcinoma
carcinoma of
of the upper lip.
the hard palate.
 DIAGNOSIS: RADIOGRAPHIC EVALUATION
• Plain radiographs, sialography, nuclear scans, and USG less diagnostic

information, seldom indicated.

• CT and MRI are equally satisfactory in differentiating cystic from solid lesions,

relationship oft the mass to the major salivary gland or adjacent structures. (Figs.
13.19-3.21).
• CT scans : assessment of bone erosion, MRI: demonstrating tumor

extension along cranial nerves.

• CT scans are invaluable in the evaluation of deep lobe parotid tumors

and differentiating them from tumors arising in the parapharyngeal

space (Figs. 13.22 through 13.25).
 T1-weighted MRI: Benign mixed
tumor in the superficial lobe left
MRI: Assessment of deep lobe parotid tumors, parotid gland.
differentiating from tumors of ectopic or minor T2-weighted MRI: Same patient
salivary gland origin.
Axial view of a contrast-enhanced T2-weighted
MRI-left parapharyngeal space, tumor of
ectopic salivary tissue. Fat separating the tumor
from adjacent deep lobe parotid tissue.
Pleomorphic Adenoma (Mixed Tumor)
• Benign, encapsulated,
• Admixture of epithelial, myoepithelial, and stromal
elements with architectural pleomorphism
• 2/3 major SG and less than ½ of minor SG.
• Superficial lobe of the parotid gland.
• Definite diagnosis might not be possible on a
representative frozen section or FNAB
• Recurrence: local regrowth, not necessarily malignancy,
many multifocal, and some widely distributed that surgical
control becomes impossible.
Pleomorphic Adenoma (Mixed Tumor)
Carcinoma Ex Pleomorphic Adenoma

• Malignant neoplasm, association with pleomorphic adenoma.

• High grade, similar histology.

• Most frequently: salivary duct, myoepithelial.

• Classified based on the degree of tumor invasion capsule.

Intracapsular, minimally invasive: A very low rate of local

recurrence and regional metastases

Invasive: High
Warthin’s Tumor (Papillary Cystadenoma
Lymphomatosum)
• Benign
• Parotid gland
• Composed of eosinophilic
glandular epithelium, lined by
basaloid cells, with papillary cystic
spaces, embedded in dense
lymphoid tissue

Oncocytoma
Oxyphil adenoma/oncocytic
Adenoma.
Benign composed of oncocytes
that are epithelial cells packed with
mitochondria, imparting a granular
appearance to the cytoplasm.
Mucoepidermoid Carcinoma
• Most common malignant SG tumor
• > 1/2 in the parotid gland, minor salivary glands: the
palate.
• Varying proportions of epidermoid (squamoid), mucous,
and intermediate cells, arranged in cystic or glandular
structures or in a solid growth pattern.
• CK5/6 and p63: Epidermoid and intermediate cells.
• Perineural and vascular invasion.
• Grade based on tumor cytologic and proliferative features
and architecture: Low, intermediate, and high grade
 Mucoepidermoid Carcinoma

Low-grade mucoepidermoid High-grade mucoepidermoid

carcinoma with more than carcinoma demonstrating
20% of the tumor represented by marked nuclear pleomorphism and
cystic spaces lined by squamoid areas of single-cell necrosis (200×
epithelial cells (25× H&E stain). H&E stain).
Adenoid Cystic Carcinoma

• Slowly growing, insidious, 15-year latency period.

• Major salivary glands, oral cavity, nasopharynx, nasal cavity,
paranasal sinuses, lacrimal glands, and lower respiratory tract.
• Composed of ductal and myoepithelial cells and hyalinized or myxoid
matrix
• Perineural ,local invasion , recurrence after surgical resection.
• Main growth patterns: Cribriform, tubular, and solid
• Grading does not significant in the prediction of the malignancy
behavior.
• Solid tumor: More aggressive, poor survival.
• Infrequent lymph node metastases; More likely distant spread to the
lungs and kidney.
 Adenoid Cystic Carcinoma

Adenoid cystic carcinoma of the parotid gland

demonstrating a predominantly cribriform
architectural pattern (50×H&E stain).
Polymorphous Low-Grade Adenocarcinoma/PLGA

• Minor salivary glands-hard palate

• Indolent course.
• Cytologic uniformity and various growth patterns. Perineural invasion
be seen.

Epithelial-Myoepithelial Carcinoma
• Indolent
• Multinodular pattern and bilayered arrangement of inner ductal cells
and outer myoepithelial cells, with classically clear cytoplasm.
Acinic Cell Carcinoma
• 10% SG carcinomas
• Indolent and low grade but have the capacity to present as high-
grade tumors.
• Almost exclusively in the parotid.
• Serous acinar

Secretory Carcinoma
• Mammary analog secretory carcinoma (MASC)
• Histologic and molecular similarities to secretory carcinoma of the
breast.
• Eosinophilic or clear bubbly cytoplasm, and they may grow as
tubules or
• microcysts, papillae, or macrocysts.
Salivary Duct Carcinoma
• Aggressive, high-grade carcinoma.
• Composed of ductal cells arranging in tubules, solid, cribriform growth
with central necrosis.
• AR, HER2 with or without amplification of the gene by fluorescence in
situ hybridization.
• Targeted therapeutic, anti-ERBB2 antibodies, androgen deprivation
therapy → variable results.

Myoepithelial Carcinoma
• Rare, composed almost exclusively of myoepithelial cells.
• Locally aggressive with diverse clinical outcome.
• Association with pleomorphic adenoma (carcinoma ex
pleomorphic adenoma).
TREATMENT
• Surgery: Mainstay of initial therapy.

• The primary goal: Gross total removal, accurate diagnosis and local

control, reduce the risk of local recurrence.

• Benign occur in the parotid gland. Superficial parotidectomy

preservation N.VII: Tumor confined to the superficial lobe, N.VII not

directly infiltrated by the tumor
• Sacrifice N.VII: Invasive tumor directly into the N.VII, resection of the

N.VII would facilitate monobloc excision.

• Submandibular salivary gland: Wider resection of adjacent soft

tissues in the submandibular triangle, ND, improve local control.

• Close margins and/or microscopically positive margins in

the vicinity of the N.VII→adjuvant radiation therapy,

respectable local control rates.
• Radiotherapy: Adjuvant, palliative, unresectable.

• No chemotherapeutic agents with predictable efficacy are

available for routine use in the treatment of salivary gland

tumors at present → only in a palliative setting.
Factors Affecting Choice of Treatment
• Low-grade, low-stage malignant tumors confined to the superficial

lobe of the parotid gland: Superficial parotidectomy.

• High-grade, high-staged: Total parotidectomy/extended radical

parotidectomy ± sacrifice N.VII ± ND.

• Advanced tumors: May require excision of the auditory canal, the

ascending ramus of the mandible, temporal bone resection.

• Loss of the hypoglossal and lingual nerves and the marginal branch

of the N.VII is not as debilitating as the loss of the entire N.VII.

• Special rehabilitative seldom for radical operations for submandibular

salivary gland tumors.

SURGICAL TREATMENT: Surgical Anatomy, The Anatomic
Relationships of The Parotid And Submandibular Salivary Glands to
Adjacent Cranial Nerves.
The parotid glands:
- Retromandibular fossae,
posterior ramus ascenden
mandible, anteroinferior
CAE.
- 80% lateral N. VII, “superficial
lobe.”
- Drains-Stensen duct, lateral
surface of the anterior
masseter-buccinator-opens to
cheek mucosa at the occlusal
dental line second upper
premolar.
Anatomic Landmarks For Intraoperative
Identification of N.VII
3 Important nerves:
N.VII: stylomastoid
foramen-cephalad posterior
belly digastric muscle,
anteroinferior CAE- parotid
measures anywhere from 5
to 15 mm, point tip mastoid,
cartilaginous auditory
canal, and superior border
posterior belly of the
digastric
muscle meet.

N. greater auricular: tail parotid, anterior and posterior branches, sensations to the
skin of the face near the tragus and the earlobe.

N. Auriculotemporal: branch of the

V.3, parasympathetic parotid by the otic ganglia.
The Anatomic Relationships Of The Deep Lobe Of
The Parotid Gland

Tumors arising in the deep lobe:

1. Prestyloid compartment of parapharyngeal/masticator space: from ectopic salivary
tissue , minor salivary glands of the lateral pharyngeal wall.
2. Retromandibular
The Anatomic Relationships of The Submandibular
Salivary Gland

The submandibular glands in the digastric triangle.

3 Nerves: The marginal branch of the N.VII, the hypoglossal nerve, and the lingual nerve.
Drain into Wharton’s duct.
The Anatomic Relationships Of The Sublingual And
Submandibular Salivary Glands to The Oral Cavity.

Sublingual glands:
• - Smallest, poorly encapsulated.
• - Beneath the mucous membrane of the floor of the mouth and the mylohyoid
muscle.
• - Drain by way of several small ducts directly into the oral cavity /into the
submandibular duct.
Excision of the Submandibular Salivary Gland
for Infection, Calculus, or Tumor
• Calculus: chronic intermittent obstruction with painful enlargement
gland
• Calculus lodged in Wharton’s duct in the oral cavity, easily palpable,
extracted intraorally.
• Does not resolve: excision of the entire submandibular gland.
• Primary tumor is small and within the capsule: en bloc excision+
LN in the suprahyoid triangle.
• Large/transgressed the capsule, involved adjacent LN: radical,
sacrifice anterior and posterior bellies of the digastric muscle;
mylohyoid muscle; hypoglossal, lingual, and mandibular branch of the
facial nerve.
Calculus of TheSubmandibula Gland

Proposed line of Incision subcutaneous

tissue, upper skin flap Further retraction of the
incision.incision.
elevated superficial submandibular gland to
platysma, mandibular caudad exposes the
and cervical branches of anterior belly DM.
N.7 are seen anterior to
the facial vein.
 Calculus of TheSubmandibula Gland

The mylohyoid muscle is Wharton’s duct is divided,

dissected up to its lateral
border
The submandibular ganglion
and the secretomotor fibers and its stump is ligated.
are clamped, divided, and
ligated.

Wharton’s duct is divided,

and its stump is ligated.
Superficial Parotidectomy for a Benign Mixed Tumor
The modified tragal incision
is outlined.
Incision through the SC
tissues.The anterior skin flap
is elevated superficial to the
platysma.
N.7 is identified, dissection
proceeds in a plane
superficial to the facial
nerve and its branches.
Posterior border superficial
lobe separated
from the auditory canal and
retracted anteriorly. Exposure
of the posterior belly of the
DM→ digastric groove.
Superficial Parotidectomy for a Benign Mixed Tumor

Dissection of the upper The surgical field after

division N.7. removal of the specimen.
Excision of a Superficial Lobe Parotid Tumor with
Extension to the Deep Lobe

Tumor n the superficial lobe
with retromandibular area
Tumor extend to the deep lobe
between the upper and lower
divisions N.7, Dissection N.7
branches to deliver the tumor
out from the deep lobe tissue
Surgical defect show
complete preservation
of all the branches N.7

Bilobed tumor with

indentation created by the
bifurcation of the facial nerve.
Excision of a Deep Lobe Parotid Tumor

Mass in The superficial lobe The deep lobe tumor is

the retromandibular region. The removed removed, N.7 preserved
main trunk N.7 identified, and its intact.
major divisions are dissected.
Excision of a Deep Lobe Parotid Tumor in the
Parapharyngeal Space

The superficial parotid lobectomy Lower division The tumor is mobilized

has been completed are gently retracted circumferentially and is
cephalad over the angle of delivered through the
the mandible to expose the retromandibular space.
retromandibular region.

The bed of the tumor in the

parapharyngeal space.
Excision of an Accessory Parotid Tumor
• A superficial parotidectomy indicated if the tumor arises from the
anterior aspect of the superficial lobe parotid tissue.

After elevation, dissection for

Incision is much
identification of the peripheral
longer to exposure
ends of the zygomatic and
of the anterior soft tissues
buccal branches. The excision of
of the cheek
the tumor is completed with a
superficial parotidectomy.
Excision of Accessory Parotid Tumor Without
Superficial Parotidectomy
• Accessory tumor is discrete and separate from the substance of the
superficial lobe

Dissection of the zygomatic Removal of the tumor

and buccal branches, showing intact zygomatic
delivery tumor from and buccal branches, the
between these two Stenson’s duct in between.
branches.
 Radical Parotidectomy With Resection of the
N.7 and Nerve Graft

The surgical field after removal of Reconstruction of the lower

the tumor with sacrifice division of the facial nerve
of the lower division N.7and the with a sural nerve graft.
masseter muscle.
 Radical Resection for Adenoid Cystic
Carcinoma of The Parotid Gland
• Firm mass developed in the preauricular subzygomatic, zygomatic arch, temporal
region.
• The surgical specimen: Entire parotid gland, a portion of the zygomatic bone and
zygomatic arch, the temporomandibular joint and condyloid process, lateral and
medial pterygoid, temporalis muscle and the coronoid, process of the mandible.

tumor in the superficial lobe The surgical defect

extending into the subzygomatic, The outline of the skin showing preservation of
masticator space, anterior and incision. the lower division of the
medial to the condyloid process facial nerve.
• Radical Resection: Auditory canal, radical
mastoidectomy, TBR and amputation of the external ear.
• Retrograde dissection of the N.7: Primary tumor of the
parotid gland arises or located in the region of the
stylomastoid foramen making dissection and identification
of the main trunk of the N.7 difficult.
• Excision of a Recurrent Tumor of the Parotid Gland
• Unifocal who previously enucleation superficial lobe or a
local excision without a formal superficial parotidectomy.
• Multifocal previous superficial parotidectomy, even
involving the overlying skin. Difficult with significant risk of
injury N.7.
Rehabilitation of the Paralyzed Face
• Facial nerve grafting: Restores spontaneous motion to the face,
potentially disabling synkinesis.
• Static procedures to support the lower eyelid: Platinum or gold
weight, chronic epiphora.
• An upper eyelid gold weight implant: Bell’s reflex and high risk
vision compromise, harmonious closure and protect the cornea.
• Mini hypoglossal nerve transfer → lower face by end-to-side
coaptation of the marginal mandibular nerve.
• Proximal nerve trunk: Transfers to zygomatic using a nerve to
masseter for smile and possibly blink. Blinking during mastication.
Rehabilitation of the Paralyzed Face
• Early postoperative: Facial paralysis with paralytic ectropion.

• 3 months Facial motion, 4 months: Smile within, 12 months: Ectropion

is mostly resolved.
• An alternate approach to dynamic smile: Labbé procedure involving

temporalis transfer to the oral commissure, immediate smile, recovery

to the eye (-).
• Brow ptosis: Browlift.

• The ALT donor site also provides an excellent source.

Factors Predictive of Outcome

The clinical stage of the disease and histologic grade.

Factors Predictive of Outcome

The impact of histologic grade on survival.

Survival in relation to the histologic type of the

primary tumor.
 Conclussion
• Rare, 3% to 6% tumors of the HN. Common in the parotid gland.

• Salivary glands: Major, minor

• Benign: Pleomorfic adenoma, Warthin’s tumor, Oncocytoma,

• Maligna: Mucoepidermoid ca, Adenoid cyst ca, Adenocarsinoma.

• Diagnosis: Physical exam, CT-Scan, MRI

• Primary goal: Gross total removal, local control, reduce the risk of local recurrence.
• Surgery: Mainstay of initial therapy.

• Sacrifice N.VII: Invasive tumor directly into the N.7, facilitate monobloc excision.

• Radiotherapy: Adjuvant, palliative, unresectable.

• Chemotherapeutic agents with predictable efficacy for routine use → only in a palliative
setting.
• Factors Predictive of Outcome: The clinical stage of the disease and histologic grade.
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