1

Salivary Gland Tumors

Professor Ravi KantMS, FRCS (Edin), FRCS (Glasg), FRCS (Ireland), DNB,

FACS, FICS, FAIS, FAMS

2

Objectives

• Setting : CME

• Audience : PG

• Time duration : 20 minutes

• Evidence based

3

Objectives

• Why

• How to diagnose

• The Natural Course of disease

• What treatment to offer

• Prognosis

• Limitations

4

Etiology-1

Epstein - Barr Virus

Childhood Irradiation

Nutritional deficiencies

UV Exposure

Genetic

5

Etiology-2•Wood & silica dust exposure

•Kerosene users

•HIV-BLL

•Benign Lymphoepithelial lesion

•HIV-NHL, Kaposi’s, Ad Cy,

•Protection: dark yellow vegetables & liver

6

 Familial occurrence of acinic cell carcinoma of the parotid gland.13: Arch Pathol Lab Med 1999

Nov;123(11):1118-20

Depowski PL, USA.

7

Epstein-Barr virus infection in salivary gland tumors in children and young adults. 

Cancer 2000 Jul 15;89(2):463-6 

Venkateswaran L,

Department of Hematology-Oncology, St. Jude Children's Research Hospital,Memphis, Tennessee, USA.

8

Signs of malignancy-1

• Painless mass

• Nerve involvement

• Dysphagia

• Skin ulceration

• Sudden increase in size

9

Signs of malignancy-2

• Symptoms of surrounding structure involvement

• Mild intermittent pain

• Numbness- mucosal, tongue, 7 n,

• 9,10,11,12 cranial nerve

10

DD-deep lobe

• Oral neoplasm

(+/- fat plane on CT or MR)

• Parapharyngeal neoplasm– Lymphoma

– Neurogenic tumor

– Paraganglioma

11

Investigations

• FNAC >90% specificity, sensitivity

• MR =ideal for deep lobe

• MR Angio

• CT-3D sialography

• 99 m Tc scan for Warthin’s, Oncocytoma, Acinic, Adeno

12

Investigations

• SPECT / FDG PET for No Neck• ICA + balloon occlusion test+XeCT• Frozen section biopsy 95%√

– Perineural invasion– LN mets– Surgical margins– Type of CA or benign 67%√

13

MR>CT

• Tumor-salivary gland interface

• Benign Vs malignant

• 7 n or Perineural evaluation

• Intracranial extension of tumor

• DD; Parapharyngeal tumors

• DD; Neurogenic tumors

14

MR>CT : Perineural spread

1. Replacement of normal perineural fat with tumor

2. Enhancement with gadolinium

3. Increased size of nerve

4. Bony erosion

5. Sclerotic margins

6. Widening of crania base channels

15

CT>MR for bone erosion

• CE-CT is better than non CE

• Base of skull involvement

• Mandible erosion

16

New strategy for the diagnosis of parotid gland

lesions utilizing 3D sialography.

Comput Aided Surg 2000;5(1):42-5  

Kosaka M, Kamiishi H, Japan.

17

3D sialography:advantages-1

(1) The structure of the acinar surface is visualized in detail.

(2) The 3D structure of the entire parotid system from Stensen's duct to the gland is shown in one image.

18

3D sialography:advantages-2

(3)The parotid gland can be assessed in the context of the bony architecture of facial bones.

(4) The surface structure of the parotid gland can be understood very easily, like a scanning electron micrograph.

19

BLL

• Sjogren’s

• Mikulicz

• HIV asso. Malignancy = K,NHL,AC

• Observe as benign

• Low dose RT

• Parotidectomy as assoc malignancy

20

Warthin’s = Papillary cyst Adenolymphoma• Benign

• Kerala coast

• Favour tail of parotid

• 10% bilateral

• Hot on isotope scan

• Older man, bilateral, left alone

21

Pleomorphic – components• Myxoid

• Mucoid

• Chondroid

• Epithelial

• Other

22

Proliferative activity in recurrent pleomorphic adenomaMIB1 antibody against the cell

proliferation associated nuclear antigen (Ki-67 antigen).

The proliferation index (MIB1 positive cells per 100 cells)

23

Proliferative activity in recurrent pleomorphic adenoma

Epithelial differentiation as a possible origin for recurrence.

Bankamp DG : Laryngorhinootologie 1999 Feb;78(2):77-80 

24

Proliferative activity in recurrent pleomorphic adenoma• Tongue like projections,

• Pseudocapsule

• 7 n palsy

• Skull base involvement

• Locally invasive

• Recurrence even multiple

25

Pleomorphic adenoma

• Malignant transformation

• Locally dangerous

No enucleation,

only

Wide margin of tissue =

Superficial parotidectomy

26

Pleomorphic adenoma & Adjuvant RT• Spill

• Residual

• Recurrent,

• Nerve encasing

• Deep lobe involvement

Rx→Postoperative Radiotherapy

27

T

• T1 <2 cm

• T2 >2-4 cm

• T3 >4-6 cm

• T4 >6 cm

28

N

• No• N1 <3 cm,ipsilateral single• N2 A >3-6 cm,ipsilateral single

B <6cm,ipsilateral multiple C <6cm, bilateral

• N3 >6 cm

29

LN

• Preauricular-

Squamous

Melanoma

Not parotid

Intraparotid

30

M

• Mo -distant mets

• M1 +distant mets

31

M

• Lung

• 40% Adenoid Cystic

• 30% Malignant Mixed

• Also with Acinic cell

• SM:P::2:1

• Lung mets In AdCy can live up to 20 years

32

Mode of Spread

• Expansion

• Local infiltration

• Lymphatics

• Perineural infiltration

• Seedling in the tumor and skin

33

Probability of cancer

Sublingual Highest 4+

Minor salivary Next Highest 3+

Submandibular Next highest 2+

Parotid Lowest 1+

34

HP & Site : %

Histology Parotid Submandibular

Acinic 11 17

ME 32 12

Adeno 16 02

Malig. mixed 14 10

35

HP & Site : %

Histology Parotid Submand.

Adenoid Cystic 11 41

Squamous 8 9

Undifferentiated 8 9

36

Acinic-1

• 16% of Parotid– of all acinic; 81% in Parotid

• 3% of all salivary

• 5th decade

• Bilateral

• More in Females

37

Acinic-2

• Types- four types

1. Solid, 2. Microcytic, 3. Papillary-cystic, & 4. follicular

• Papillary cystic 100% mortality

• Solid has equally worse prognosis

• Node +, Nerve+, Margin +,T3-T4

= poor prognosis

38

Acinic-3• 5,10,15 yr survival in %= 100,87,65 • Local recurrence 15%• Distant Mets 10%• Facial palsy 0-8%• Regional N0-16%• Adjuvant RT in T3,T4, N+• Improper Rx = recurrence rate 75%,

N+ 25%

39

Adenoid Cystic-1• Billroth 1854 Cylindroma

• Minor 31%, Submand 41%

• Perineural invasion in 80%, ↑ if >1cm

• Types: Tubular, Cribriform and Solid

• Solid has worst prognosis,

• High grade or low grade

• 10 yr survival in high grade is 0%

40

Adenoid Cystic-2

• Prognosis- T, Bone invasion, Nerve+, Grade,DNA ploidy, best with tubular

• LN+ is rare <8%, lethal 6% @10 yr

• No role of elective neck dissection

• Site 10 yr survival

= 29% parotid, 7% paranasal

41

Adenoid Cystic-3

• Adj RT for local control as recurrence 37%

• No solution to distal mets 40%, up to 20 years

• Mets to lung 63%, Bone & liver• Survival @ 5y =69%, @ 20y=22%

even in favorable grade• 1/3 free,1/3 dead,1/3 recurrence

42

Muco epidermoid

• Gr 1 Well differentiated

• Gr 2 Moderate

• Gr 3 Poorly

• Grade Low or High

• Death in 5y LGME 6%, HGME 65%

• Agnor count ά prognosis

43

Malignant mixed-1

• 4% = CA Ex pleomorphic =epithelial

• Risk 1.5% <5y long, 9.5% after 15 y

• Risk 7% with recurrent Pleomorphic

• Risk if 20y long, >2cm, age, deep lobe, solitary nodule, previous surg

• de-novo = carcinosarcoma, 5y =0% S

44

Malignant mixed-2

• < 8mm invasion, 5y survival = 100%

• > 8mm invasion, 5y survival =<50%

• Survival 5y=40%,10y=24,15y=19%

• Regional mets 25%;Distant mets 33%

• Types:1. CA ex pleo;2. CASA, 3.Metastasizing mixed, 4. Non-invasive

45

Large Tumors: General Principle:• Failure at distant site

• Role of Postoperative RT

• Avoid Marked mutilation &

Physiological compromise

• Lung mets not preclude rx of primary

46

Rx

• Superficial / Total parotidectomy

• Save 7th Nerve,

– if not directly involved ?

– 56% recurrence even if nerve excised

• Submandibular triangle resection

47

LN %Salivary CA 14

Low grade ME 2

High grade ME 44

48

LN % in Clinical NoClinical No neck Surg

•High grade 49

•Low grade 7

•Epidermoid 41

•All other 10

49

LN %in Clinical No

T1 7

T2 7

T3 16

T4 24

50

LN % in Clinical NoClinical No neck Surg

•Submandibular 21

•Parotid 9

•Ectopic 10

51

SOHD of Neck- Indications

• T4 20% vs 4%

• T3 16% vs 4%

• High grade ME 49% vs 7%

• Epidermoid 41% vs 7%

• Skip 25% L3+ or 4 + but L2-

• Submandibular 21% vs 9% in P

52

VII nerve• Neuropraxia up to 6 months

• Interposition of

– Great auricular

– Sural

53

VII nerve

• Fascia lata sling

• Muscle transfer

• Lateral tarsorrhaphy

54

Adjuvant RT in high grade, LN+, Stage III or IVStudy -RT +RT

5 yr survival 28 57

5 yr local control 44 63

+ margin 54 14

Low grade tumor No benefit

No benefit

55

Indication for Adjuvant RT-1

In benign• Spill • Residual• Recurrent, • Nerve encasing• Deep lobe involvement• After excision of residual tumor

56

Indication for Adjuvant RT In malignant

1. Recurrent

2. Residual, positive margin,

3. Narrow margin on facial nerve

4. Multiple nodal involvement

5. Perineural invasion

6. High grade locally aggressive

57

Indication for adjuvant RT-3

All submandibular tumors

-except T1,T2, Acinic or LGME

All adenoid cystic tumors

All T3, T4,

All N+

58

Adjuvant RT

• Wedged photon pair• Mixed plan= Ipsilateral photon

+ Electron beam• Fast Neutron therapy• Brachy therapy

59

Adjuvant RT: Choice is Fast neutron therapy

• 67% Vs 26% rr with photon or electron.

• 2 yr survival 55% vs 13%

• Therapy of choice in inoperable, recurrent, or residual

• More toxic

• Failure due to distant mets 20% vs. loco regional failure in photon

60

Survival % : 5year

Parotid 50-81

Submandibular 30-50

61

Histology: Survival %

Tumor 5 yr 10 yr 15 yr

Acinic 75 65 44

Low grade ME 70-95 50

High grade ME 30-50

Adenoid cystic 50-90 30-67 25

Adeno 76-85 34-71

Malig. mixed 31-65 24 19

62

Summary• P/E = Mucosal numbness

• FNAC + MR + 3D CT

• No role of enucleation in benign- Minimum is supf parotidectomy

• RND in HGME,T3,T4, AdCy,S

• Role of Adjuvant RT – yes

• Fast neutron is best.

• Chemo ???? As distant mets in 20%

63

Future

• Brachy therapy

• Better than Fast Neutron therapy

• Reliable tumor marker

• Newer Imaging modalities

SPECT for No

• ??? Role of any chemo for Rx of distant mets