dr.

Bob Andinata, SpB(K)Onk

• Medan, 17 November 1974

• bobandinata@gmail.com
• RS. Kanker Dharmais, Staf Dokter Bedah
Onkologi, April 2013 – sekarang.
• RS. Kanker Dharmais, Ka. Instalasi Rawat
Jalan, 2016 - sekarang.
Surgical Aspect of
Locally Advanced
Salivary Gland
Carcinoma

Bob Andinata
5th JSOF
Jakarta, June 28th 2019
 Salivary Glands (SG)
• Major (Parotid, Submandibular & Sublingual)
• Minor (submucosal of upper aerodigestive
tract; nasal cavity to esofagus – trachea )
• Neoplasma of Salivary Glands are rare
• 3% - 6% of all tumors of the head neck region
Incidence of Tumors
among SG

25% 80% 50%

Origin Sites of Minor SG Tumors
Distribution of SG Cancer

65% 8% 27%
 Introduction
• <1% of all malignancies
• 4-5% of head neck malignancies*
• <0,5% of all cancers diagnosed yearly in USA,
with an incidence of only 1-2 per 100,000
individuals *

* Adriane P. Concus, & Theresa N. Tran, Malignant Diseases of the Salivary Glands, Current Diagnosis & Treatment in
Otolaryngology – Head & Neck Surgery 3rd Edition. A Lange Medical Book. New York University School of Medicine. New York.
2012
 Diagnosis
• Clinically history and location of the lump
• Sign and Symtomp of Fascialis Nerve Infiltration
• Imaging : Ultrasound, CT Scan, MRI or PET Scan
• FNAB for malignant : 80-90% sensitive
• Routinely performing FNAB is still debating
• Open Biopsy  unresectable
Imaging Modalities & Strategies for Diagnosis
and Staging for Head Neck : Parotid Gland
 How is the Treatment ?

• Salivary gland
cancer is
a Surgical Case
 Parotidectomy
• German surgeon Lorenz Heister described the
first parotidectomy in 1765 to treat ranula and
stones at the floor of the mouth.
• John Hunter (1728-1793) a Scottish surgeon,
in October 24th, 1785 resected a bulky parotid
tumor without complication, as described in
his “Case Books”
• In 1805, George McClellan, professor
at Thomas Jefferson University,
performed the first parotidectomy
due to cancer in USA. He operated
more than 30 patients, 11 been
submitted to total resection with
sacrifice of facial nerve. Described in
his book “ Principles and Practice of
Surgery” of 1848
• In 1892, Codreanu performed the first
total parotidectomy with preservation
of facial nerve.
• In 1923, Alfred W. Dson and Willian O.Ott,
described to localization of facial nerve trunk
retrogradely.
• 1952, Hayes Martin from
Memorial Sloan Kettering
Hospital New York wrote
that the facial nerve trunk
should be routinely
performed initially, before
resecting the parotid
gland tumor.
How about the future ?

• Endoscopic Surgery
• Robotic Surgery

Uncommon in Head neck Surgery

 Role
In Treatment Selection & Clinical Outcomes

Histology Grade

TNM
Staging
 TNM Stage grouping. Parotid gland cancers are highly varied
histopathologically and perineural invasion of the VIIth and Vth
cranial nerves are the major concern.
Metastasis
Salivary Gland Carcinoma
Group Staging

Metastatic  Paliatif

Locally  Currative
Advanced Intent

Early Currative
 WHO
Classification
of SG
Malignant
Neoplasms
 The Different Histologic Variants of SG
Malignancies
miscellinous 3%

Squamous cell carcinoma 4%

Acinic cell ca 7%
Malignant mixed tumor
13%
Adenocarcinoma
18%
Adenoid cystic ca
22%
Mucoepidermoid ca

0% 5% 34%
10% 15% 20% 25% 30% 35%
*Data from Spiro RH. Salivary neoplasms : overview of a 35-year experience with 2,807 patients.
Head Neck Surg 1986;8:177
Distribution of Various Types of
SG Malignant Tumors
 Mucoepidermoid Ca
• Most commom type
• Parotid gland (80-90%), 2nd in palate (minor SG)
• 5th decade of life, with a female 4:1 dominant
• Classified as low, intermediate and high grade
• Aggressiveness, local invasion and lymph node
metastases are all greater
• 5-year survival rate for low grade = 70% and high
grade = 47%
 Adenoid Cystic Ca
• Most common type in Submandibular,
Sublingual and Minor SG
• Frequency men = women
• Perineural spread ,skip lesions & discontinous
area of spread along a nerve (80% of cases)
• Lymphatic spread and distant metastases are
uncommon
• Survival rate : Parotid > Minor SG
 Acinic Cell Ca
• 80-90% occurs in Parotid, 2nd in
Submandibular
• 5th decade of life, with women > men
• Low-grade malignancy
• OS rate 5 & 10 years = 78% & 63%
 Adenocarcinoma
• Most differentited form, range from low grade
to high grade
• Many categorized, such as polymorphous low-
grade adenoca, epithelial-myoephithelial ca,
salivary duct ca and adenoca NOS
 Malignant Mixed Tumors
• Most common variant  Ca ex-pleomophic
adenoma (75% in Parotid)
• The malignant part could be an adenoca, a scc, an
undiff ca, or etc
• A true variant : carcinosarcoma is very rare
• Classified as high grade
• Invasion, locoregional and distant metastases are
common
• The 5-year survival rate is <10%
 Grade
Classification
of SG
Malignant
Neoplasms
Surgical Selection

Role Philosophy
Philosophy of Head Neck Surgery

Currative

Function
Aesthetic
 Masterpiece of
Parotid Surgery
Adopt from larianmd.com

“ How to Identify Facial N. trunk & branches “

Supporting :
Intraoperative nerve
monitoring unit
Landmark of
7th Nerve
Identification of N. Facialis Trunk
 Early Stage

Identification & Margin

Preservation of
Fascialis Nerve
Metastatic

How
Debulking
Release to symtomp
of closure
Locally Advanced

Radical
Adjuvant
Recons Surgery
truction
 Types of Surgery in Locally
Advanced
• Total parotidectomy w/o preservation of
facialis nerve
• Radical resection : infiltrated adjacent
tissue
• Radical Neck Dissection
 Data from Dharmais Hospital
2018-2019
No sex age stage pathology Surgery / reconstruction Survive

1 F 52 TxN0M0 Acinic cell ca Total Prtd +

2 F 57 TxN0M0 Adenoid cystic ca Total Prtd ?

3 M 60 T4aN0M1 MEP ca, high grade Radical Prtd -- (11 mo)

(lung)
4 M 56 T4aN0M0 MEP ca, high grade Radical Prtd ?

5 F 73 T4aN1M0 SCC Radical Prtd +

Local flap & nerve graft
6 F 57 T4aN1M1 MEP ca, high grade Radical Prtd +
(lung) LD flap
7 M 50 T4aN0M0 SCC Radical P Local flap -- (5 mo)

8 F 53 T2N0M0 Adenoid cystic ca Total Prtd ?

9 F 59 T4aN1M0 MEP ca, high grade Radical Prtd -- (4 mo)

Free flap  deltopectral flap
10 M 70 T4aN1M0 Acinic cell ca Radical Prtd +
Free flap
 Mr. B, 70 yo
Acinic cell ca Parotid
Stage IVA
 Mrs. R, 59 yo
Mucoepidermoid Ca Parotid
Stage IVA

Surgery on February 2019

Chemoradiotherapy on April  Residif
Passed away on June
Surgery of Locally Advanced Salivary Gland
Carcinoma

Aggresive
Conservative

Do
Nothin
g
 Resume
• Diagnosis and Staging
• Pre-surgical plane of CT Scan or MRI
• Determine curative or palliative setting
• Based on Role and Philosophy
• Key to find Fascialis Nerve and the branches
• Recontruction for wound or Nerve
• Adjuvant Treatment
Thank
You
 Refferences
1. Jatin Shah E-book
2. Surgical Oncology Textbook p.992
3. Head Neck Otolaryngology, ebook p.354
4. NCCN Guidelines p.78, 176
5. TNM Atlas chapter 6, p.62
6. Management of salivary gland carcinoma – a
review Journal
7. Data from Dharmais Hospital 2018 – 2019