Premanagement in Salivary Gland Tumors

7/31/2019 Premanagement in Salivary Gland Tumors

1/40

Click to edit Master subtitle style

7/8/12

Premanagement in

Salivary Gland TumorsDr Sasikumar SambasivamModerator: Dr Nidhi Patni


2/40

7/8/12

Anatomy


3/40

7/8/12

Anatomy


4/40

7/8/12

y


5/40

External carotid A

RetromandibularVein

Facial NerveSuperficialtemporal A

MaxillaryA

P.AuricularA

Superficialtemporal V

MaxillaryV

Post auricularVExternal

jugularCommon FacialV

FacialNerve

temporal

buccal

mandibular

cervical

zygomatic

Zygomaticotemporal

Cervicofacial

Parotid


6/40

gland


7/40

gland


8/40

Ducts


9/40

7/8/12

Neural Str.Major Gland Cranial Nerve Foramina of base of skull

ParotidSuperficial

Deep

7

9,10,11,12

Stylo mastoid foramen

Jugular foramen andHypoglossal canal

Sub mandibular V3,7 (mand and cervical br.),12

Foramen ovaleStylomastoid foramenHypoglossal canal

Sub lingual V3 Foramen ovale


10/40

7/8/12

The Saliva

Serous (Parotid and Von Ebner)

Viscous (Sublingual & Minor )

Mixed (Submandibular &Sublingual)

Parotid-25 % of total saliva secretion Submandibular-60%

Sublingual-5%


11/40

Click to edit Master subtitle style

7/8/12

unc onsbriefing

Saliva

Anti-Bacterial

Buffering

Digestion

Mineral-

izationLubricat-ion&Visco-elasticity

TissueCoating

Anti-Fung

al

Anti

-Viral

Carbonic

anhydrases,Histatins

Amylases,Mucins,

Lipase

Cystatins,

Histatins,Proline-rich proteins,Statherins

Mucins,Statherins

Amylases,Cystatins, Mucins,

Proline-rich proteins,Statherins

Histati

ns

Cystatins,

Mucins

Amylases,

Cystatins,Histatins,Mucins,Peroxidases


12/40

7/8/12

ymp o es oParotid

Peri and Intraparotid Level 1B,2,3, RPnodes; C/L nodes if T crosses midline


13/40

7/8/12

ofSub Mandibular Level IB

Level2 Level 3

Sub Lingual Level IA Level

1B- Level 2


14/40

7/8/12

p em o ogy

3-4% of all H & N neoplasms In gen

-Parotid>SubMandibular>SubLingual

Parotid: 80% benign, Submandibular: 50% benign

Sublingual : Most are malignant

Age factor:

Benign: 40 M>F; Malignant: 55yrs M=F

3% of all in Children ,half are malignant.

i l


15/40

7/8/12

Aetiology Unknown

Radiation Induced(Modan et al)

Nutritional deficiency(A &C)

Infection EBV UV rays controversial

Cigarettes ,Alcohol, hair dyes, higher

educational level ? Ass. With Breast cancer(2.5 fold

increase)


16/40

7/8/12

Pathology

Benign:

Pleomorphic Adenoma

Papillary Cystadenoma Lymphomatosum(Warthin Tumor)

Benign Lymphoepithelial Lesions (GodwinTumor)

Oncocytoma

Basal Cell Adenoma


17/40

7/8/12

-types(WHO)

Acinic cell carcinomaMucoepidermoidcarcinomaAdenoid cystic carcinomaPolymorphous LG adenocaEpithelial-myoepithelial

caBasal cell adenoca

Sebaceous caPapillary cystadeno caMucinous adeno ca

Oncocytic carcinomaSalivary duct carcinoma

Adeno caMyoepithelial ca

Ca in pleomorphicadenomaSquamous cell

carcinomaSmall cell carcinoma


18/40

7/8/12

g Low grade

Acinic cell ca

Muco epidermoid (LG)

High grade

Mucoepidermoid(HG) ca

Adeno ca / PD/Anaplastic

Malignant Mixed

Adenoid Cystic

Lymphoepithelioma(Eskimoma)


19/40

7/8/12

.types :TYPE %

Parotid (n = 1778 cases)

Mucoepidermoid 32Adenocarcinoma 16

Malignant mixed 14

Adenoid cystic 11

Acinic 11

Undifferentiated and squamous 16

Submandibular (n = 383 cases)

Adenoid cystic 41

Acinic 17

Malignant mixed 12

Mucoepidermoid 10

Undifferentiated 9

Squamous 9

Adenocarcinoma 2

Data from Memorial Sloan-Kettering Cancer

en gn P eomorp ic


20/40

7/8/12

en gn: P eomorp icadenoma

Parotid > Sub mandibular

Painless,slow growing ,Ipsilateral andmore in females

Has a pseudo capsule; Recurrence after

excision common 5-10% chance for malignant

transformationPapillary Cystadenoma

LymphomatosumWarthin tumor, confined to parotid(Tail)B/L in 10% ;more in older men;Recurrence rare after surgery


21/40

7/8/12

conditions:Mucoepidermoid ca:

MC malignancy of SG;90% in parotids f/bHard palate and minor SGs.

Majority are slow growing

Most frequent SG tumor in children

Behavoiur WD vs PD

Adenocarcinoma:


22/40

7/8/12

Malignant Mixed Tumors

From benign conditions like Pas

Pathlogically carcinosarcomas

Aggressive behaviour with 20% risk oflocal recc.

Propensity of LN mets >25%

Carcinoma Ex Pleomorphic

Adenoma


23/40

7/8/12

Adenoid Cystic Carcinoma:

MC type in Submandibular and Minor SGs

Solid HP (Undiff)- more malignantbehaviour

Typical natural history

LN mets rare(


24/40

7/8/12

Histology

Incidence

AgePredil.(Decade)

SexPredil.

Favored Site

NodeMets

7thNerveInv.

Recurr.DistantMets

Aciniccellcarcinoma

4 5th F > M Parotid 10 3 10-22 Rare

Adenoidcystic

carcinoma

2-5 5th-6th F = M

Minor

salivary15 26 High* 28

Mucoepidermoidcarcinoma

Lowgrade

1st-2nd 8 17

17-20 4th-5th M > F None 60 33

Highgrade

6th High* 75


25/40

7/8/12

Histology

Incidence

AgePredil.(Decade)

SexPredil.

Favored Site

NodeMets

7thNerveInv.

RecurrDistantMets

Malignantmixedtumor

4 7th M > F

Parotidandsubmaxillaryglands

33 14 30-40 31

Squamous cellcarcinoma

0.1-3 None None

Parotidsandsalivaryduct

High* High* 70 High*

Adenocarcinoma

2.8 5th-6th None Parotid 50 9 67 19

Undifferentiatedcarcinoma

3 7th-8th F > M None 50 23 High* 30


26/40

7/8/12

SpreadHistologic Subtypes (%)

Anaplastic 86

Epidermoid 21

Adenocarcinoma 22

Mucoepidermoid 14

Malignant mixed 16

Acinic 2

Adenoid cystic 2

Oncocytoma 0

Data from Armstronget al

Swellings related


27/40

7/8/12

Swellings relatedto SGs

Mucocoele

Ranula

Necrotising Sialometaplasia


28/40

7/8/12

Presentation Painless slow growing mass in most of

benign.

1/3rd of parotid ca CN 7 inv. But only10-20 % present with pain

Multiple CN inv in case of PNI tumors

Parotid masses mostly in tail.

Most malignant salivary gland tumors areseen in patients 5060 years old, 2% inchil-dren


29/40

7/8/12

n ca ors omalignancy

Facial nerve involvement

Indurations / ulceration of skin , mucousmembrane

Lymph node metastasis

Rapid tumor growth


30/40

7/8/12

massMetastases to intraparotid nodes/ Lymphoma

Reactive adenopathy

Fatty tail of parotid

Chronic parotitis

Sarcoidosis

HIV infection

Calculus in duct with obstruction

Neoplasms of mandible

Cysts (dermoid, bronchial cleft)

Prominent transverse process of C1 vertebra

Hemangioma, lipoma, lymphangioma


31/40

7/8/12

History Local invasion is the initial route

,depending on location and histologictype. In Parotid ca -fixation to structuresin 20%.

Skin invasion is more often seen inparotid tumors (10%), compared withsubmandibular tumors (3%)

Approximately 25-35% of patients with a

malignant parotid salivary gland tumorpresent with facial palsy from cranialnerve invasion.

Lymph node involvement for parotid


32/40

7/8/12

History LN mets Parotid-18%,SM-28%,

Tumors from oral cavity presents withcervical node metastases of less than10%.

Nasopharyngeal SG tumors have a highrisk of occult metastases (50%)

The risk of + findings in the neck may be

based on a combination of T-stage andhistology.The highest risk -for SCC, UDC,and salivary duct cancer

Distant Mets lung>bone >liver.

k


33/40

7/8/12

Work up History and clinical examination esp.

CN,trismus Basic Investigations-CBC , CXR

FNAC

CT or *MRI Indications: (1) deep lobeparotid tumors, (2) neurologicallysymptomatic tumors, (3) recurrent

tumors, and (4) large size (5) Minor SGtumors

In secondary dep. in SGT -- work up for

the primary.


34/40

7/8/12

-Malignancy


35/40

7/8/12

NX Cannot be assessed


36/40

7/8/12

N0 No LN mets

N1 I/L single 3 - 6 cm

b I/L multiple < = 6 cm

c B/L, C/L 6 cm

M0 No Distant Mets

M1 Distant Mets

Stage 1 T1 N1 M0

Stage 2 T2 N0 M0

Stage 3 T3 N0 MO T1-T3 N1 M0

Stage 4 A T4a N0/ N1 M0 T1-T4a N2 M0

Stage 4 B T4b Any N M0 Any T N 3 M0

Stage 4 C Any T Any N M1


37/40

7/8/12

Descriptors

Residual Tumor (R)

RX: Presence ofresidual tumor

cannot be assessedR0: No residual

rognos c


38/40

7/8/12

rognos cFactors

Grade , postsurgical residual disease &

LN status.High grade tumors- 49% LN mets.

Size of LN

EC Extn from LN Clinical location of Cervical LN

ECS -clinical and pathological

Larger T size & CN inv.--poor prognosis.

Adenoid cystic, ductal, andundifferentiated carcinoma -highest

rates of distant mets.


39/40

7/8/12

on

Spiro et al. (434 Patients, MSKCC) 90% treated surgically

Cause specific 5yr cure rate 44%,10y-

32%,15y-21% Mortality -51% due to original cancer

Adenoid cystic- poorest prog, about 20%

surv w/o recurrence Adeno ca- IM outlook, about 35%w/o

recurrence

Mucoepidermoid ca-Best control rate, about


40/40

7/8/12

Thank

Date post:	05-Apr-2018
Category:	Documents
Upload:	dr-sasikumar-sambasivam
View:	222 times
Download:	0 times

Premanagement in Salivary Gland Tumors

Documents