Download - Salivary Gland Tumors
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Salivary Gland Tumors
Professor Ravi KantMS, FRCS (Edin), FRCS (Glasg), FRCS (Ireland), DNB,
FACS, FICS, FAIS, FAMS
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Objectives
• Setting : CME
• Audience : PG
• Time duration : 20 minutes
• Evidence based
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Objectives
• Why
• How to diagnose
• The Natural Course of disease
• What treatment to offer
• Prognosis
• Limitations
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Etiology-1
Epstein - Barr Virus
Childhood Irradiation
Nutritional deficiencies
UV Exposure
Genetic
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Etiology-2•Wood & silica dust exposure
•Kerosene users
•HIV-BLL
•Benign Lymphoepithelial lesion
•HIV-NHL, Kaposi’s, Ad Cy,
•Protection: dark yellow vegetables & liver
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Familial occurrence of acinic cell carcinoma of the parotid gland.13: Arch Pathol Lab Med 1999
Nov;123(11):1118-20
Depowski PL, USA.
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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.
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Signs of malignancy-1
• Painless mass
• Nerve involvement
• Dysphagia
• Skin ulceration
• Sudden increase in size
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Signs of malignancy-2
• Symptoms of surrounding structure involvement
• Mild intermittent pain
• Numbness- mucosal, tongue, 7 n,
• 9,10,11,12 cranial nerve
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DD-deep lobe
• Oral neoplasm
(+/- fat plane on CT or MR)
• Parapharyngeal neoplasm– Lymphoma
– Neurogenic tumor
– Paraganglioma
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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
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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%√
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MR>CT
• Tumor-salivary gland interface
• Benign Vs malignant
• 7 n or Perineural evaluation
• Intracranial extension of tumor
• DD; Parapharyngeal tumors
• DD; Neurogenic tumors
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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
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CT>MR for bone erosion
• CE-CT is better than non CE
• Base of skull involvement
• Mandible erosion
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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.
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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.
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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.
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BLL
• Sjogren’s
• Mikulicz
• HIV asso. Malignancy = K,NHL,AC
• Observe as benign
• Low dose RT
• Parotidectomy as assoc malignancy
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Warthin’s = Papillary cyst Adenolymphoma• Benign
• Kerala coast
• Favour tail of parotid
• 10% bilateral
• Hot on isotope scan
• Older man, bilateral, left alone
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Pleomorphic – components• Myxoid
• Mucoid
• Chondroid
• Epithelial
• Other
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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)
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Proliferative activity in recurrent pleomorphic adenoma
Epithelial differentiation as a possible origin for recurrence.
Bankamp DG : Laryngorhinootologie 1999 Feb;78(2):77-80
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Proliferative activity in recurrent pleomorphic adenoma• Tongue like projections,
• Pseudocapsule
• 7 n palsy
• Skull base involvement
• Locally invasive
• Recurrence even multiple
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Pleomorphic adenoma
• Malignant transformation
• Locally dangerous
No enucleation,
only
Wide margin of tissue =
Superficial parotidectomy
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Pleomorphic adenoma & Adjuvant RT• Spill
• Residual
• Recurrent,
• Nerve encasing
• Deep lobe involvement
Rx→Postoperative Radiotherapy
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T
• T1 <2 cm
• T2 >2-4 cm
• T3 >4-6 cm
• T4 >6 cm
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N
• No• N1 <3 cm,ipsilateral single• N2 A >3-6 cm,ipsilateral single
B <6cm,ipsilateral multiple C <6cm, bilateral
• N3 >6 cm
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LN
• Preauricular-
Squamous
Melanoma
Not parotid
Intraparotid
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M
• Mo -distant mets
• M1 +distant mets
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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
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Mode of Spread
• Expansion
• Local infiltration
• Lymphatics
• Perineural infiltration
• Seedling in the tumor and skin
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Probability of cancer
Sublingual Highest 4+
Minor salivary Next Highest 3+
Submandibular Next highest 2+
Parotid Lowest 1+
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HP & Site : %
Histology Parotid Submandibular
Acinic 11 17
ME 32 12
Adeno 16 02
Malig. mixed 14 10
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HP & Site : %
Histology Parotid Submand.
Adenoid Cystic 11 41
Squamous 8 9
Undifferentiated 8 9
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Acinic-1
• 16% of Parotid– of all acinic; 81% in Parotid
• 3% of all salivary
• 5th decade
• Bilateral
• More in Females
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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
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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%
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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%
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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
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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
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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
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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
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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
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Large Tumors: General Principle:• Failure at distant site
• Role of Postoperative RT
• Avoid Marked mutilation &
Physiological compromise
• Lung mets not preclude rx of primary
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Rx
• Superficial / Total parotidectomy
• Save 7th Nerve,
– if not directly involved ?
– 56% recurrence even if nerve excised
• Submandibular triangle resection
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LN %Salivary CA 14
Low grade ME 2
High grade ME 44
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LN % in Clinical NoClinical No neck Surg
•High grade 49
•Low grade 7
•Epidermoid 41
•All other 10
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LN %in Clinical No
T1 7
T2 7
T3 16
T4 24
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LN % in Clinical NoClinical No neck Surg
•Submandibular 21
•Parotid 9
•Ectopic 10
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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
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VII nerve• Neuropraxia up to 6 months
• Interposition of
– Great auricular
– Sural
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VII nerve
• Fascia lata sling
• Muscle transfer
• Lateral tarsorrhaphy
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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
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Indication for Adjuvant RT-1
In benign• Spill • Residual• Recurrent, • Nerve encasing• Deep lobe involvement• After excision of residual tumor
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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
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Indication for adjuvant RT-3
All submandibular tumors
-except T1,T2, Acinic or LGME
All adenoid cystic tumors
All T3, T4,
All N+
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Adjuvant RT
• Wedged photon pair• Mixed plan= Ipsilateral photon
+ Electron beam• Fast Neutron therapy• Brachy therapy
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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
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Survival % : 5year
Parotid 50-81
Submandibular 30-50
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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
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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%
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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